Our Experience: Strong Foundations Accelerate Change in Diversity and Cultural Competence

Physicians refer patients to MTM pharmacists at Fairview

How does the integration of health and justice systems impact on health and care inequalities in marginalised populations? A mixed methods systematic review.

You have accessThe ASHA LeaderOn the Pulse1 Jan 2011New Hospital Standards Will Improve CommunicationAccreditation Guidelines Address Language, Culture, Vulnerability, Health Literacy Sarah Blackstone, PhD, CCC-SLP Kathryn Garrett, andPhD, CCC-SLP Amy HasselkusMA, CCC-SLP Sarah Blackstone Google Scholar More articles by this author , PhD, CCC-SLP, Kathryn Garrett Google Scholar More articles by this author , PhD, CCC-SLP and Amy Hasselkus Google Scholar More articles by this author , MA, CCC-SLP https://doi.org/10.1044/leader.OTP.16012011.24 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In http://www.asha.org/Publications/leader/2011/110118/New-Hospital-Standards-Will-Improve-Communication.htm Hospitals seeking accreditation from the Joint Commission, a nonprofit agency that accredits health care organizations, must now adhere to new and revised standards intended to ensure that health care providers communicate appropriately and effectively with patients. The new patient-centered communication standards are designed to have a positive influence on patient-provider communication and on the quality of hospital care (Joint Commission, 2010a). They focus on all patients having their communication needs met. In particular, standards support communication for the most vulnerable patients: those who have no voice; have hearing, vision, or cognitive impairment; speak a language other than English; have limited literacy or knowledge about health care; or have sexual identity, cultural, or religious differences. The Joint Commission’s action is a direct response to research that links poor patient-provider communication with negative health outcomes and increased costs (Joint Commission, 2009; Bartlett, Blais, & Tamblyn, 2008; Joint Commission, 2010b). To help facilities implement these standards, which took effect Jan. 1, the Joint Commission developed a how-to guide, Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (Joint Commission, 2010a; see sidebar at right). Speech-language pathologists and audiologists have a unique opportunity to share their knowledge and skills by implementing communication strategies in hospitals for individuals who face communication barriers and breakdowns. Both professions need to join with compliance officers, risk-management teams, nurses, doctors, and other hospital staff and build collaborative relationships with interpreters, translators, clergy, and others who are being asked to support effective and appropriate patient-provider communication. Case Study A case study illustrates many of the challenges to effective communication in hospitals: Mr. G., 82, is a widowed Italian-American who emigrated to the United States 50 years ago to work in the steel mills. He has limited literacy skills and interacts primarily within the immigrant Italian community. He was recently hospitalized for an aortic aneurysm, which was successfully repaired surgically. Following surgery, Mr. G., a long-time smoker, developed respiratory complications and was transferred to the intensive care unit (ICU) and intubated with mechanical ventilation. Because Mr. G. was often combative when alert and frequently attempted to extubate himself, anxiolytic medications were prescribed to calm him. His visitors spoke to him only in Italian. He often became visibly upset after they left, refusing to take medications and attempting to get out of bed. Members of the medical staff tried to establish rapport with him, but were unable to discuss treatment options. Mr. G.’s daughter indicated that her father was hard of hearing, but he did not have hearing aids. Clearly, appropriate care for Mr. G.’s current and potential health care concerns must address several issues: maintaining ventilation and medication to improve pulmonary health, decreasing anxiety about procedures to minimize the need for medication, and addressing end-of-life issues and discharge planning. However, Mr. G.’s scenario presents several barriers to successful patient-provider communication: Language issues. Although Mr. G. understood and spoke some English, his primary language was Italian. The hospital staff spoke only English. Communication vulnerability. ICU nurses couldn’t understand Mr. G. because of the barriers posed by intubation and limited English. Also, Mr. G. didn’t understand the nurses because they spoke rapidly, did not look directly at him when speaking, and did not recognize his hearing difficulty. The room was very noisy. Anti-anxiety medication occasionally made him groggy. Health literacy. Mr. G. did not understand why he was in the ICU or what was happening to him. He was confused by the consent forms. Because he would not sign, some procedures could not be administered. Verbal attempts to inform him were not successful. Cultural supports. Discussing end-of-life issues with social workers, Catholic clergy, or family in culturally appropriate ways would be difficult given Mr. G.’s medical condition and treatment, as well as his speech, language, and hearing problems. New Standards The new Joint Commission standards will help in the effort to remove barriers to successful patient-provider communication. The standards include the following provisions: The medical record contains information that reflects the patient’s care, treatment, and services (Standard RC.02.01.01). This information includes “the patient’s communication needs, including preferred language for discussing health care.” According to this standard, Mr. G.’s language and hearing issues must be identified at admission and documented in the medical record. For example, after asking Mr. G. to point to his preferred language on a pictorial admissions form, the hospital likely would provide a trained interpreter to obtain a valid health history. The hospital communicates effectively with patients when providing care, treatment, and services (Standard PC.02.01.21). Under this standard, hospitals will identify and address oral and written communication needs—including cognitive, speech, hearing, and vision issues; preferred language; and health literacy—throughout the “course of care.” Thus, a referral to the speech-language pathology/audiology departments could be initiated at admission. Following a brief assessment (Garrett, Happ, Costello, & Fried-Oken, 2007), an SLP might provide Mr. G. with simple AAC supports and training (e.g., a nurse call signal, a tablet and gel pen, a simple voice output device, or a low-tech communication board containing needs-based messages and questions in Italian and English). The SLP also might coach the ICU staff to speak slowly and directly to Mr. G., using visual supports to augment his comprehension. An audiologist might provide a temporary amplification device, marking the on/off switch and posting a chart explaining its operation. Medical instructions (consents, explanations of ventilation and tracheotomy, etc.) could be in plain language, with Italian and/or pictures to increase comprehension. The hospital respects, protects, and promotes patient rights (Standard RI.01.01.01). This standard indicates that hospitals will allow for the presence of a support individual of the patient’s choice, unless the individual’s presence infringes on others’ rights or safety or is medically or therapeutically contraindicated. At admission, Mr. G. could ask that his daughter be allowed to stay with him and talk to the doctors and nurses. Staff could use the “teachback” method—ask Mr. G. to retell information (via translators, if necessary) to ensure he comprehends consent forms and instructions (Weiss, 2007). Clinicians’ Contributions Audiologists, SLPs, and other health care providers can take several steps to help ensure that hospitals and providers advance the effort to enhance patient-centered communication: Become familiar with the new Joint Commission Standards and the accompanying Roadmap (search “patient-centered communication”). Talk with your medical colleagues and find out how to get involved. Audiologists and SLPs can expand the influence of the field of communication sciences and disorders (CSD) while influencing policy and practice and improving the quality of health care and patient outcomes. Establish collaborative relationships with nurses, sign language interpreters, translators, and health care staff involved in implementing the new standards. Explain to hospital administrators that CSD professionals can help implement standards. Inform compliance officers, hospital administrators, and risk management teams of SLPs’ and audiologists’ specific expertise with a broad range of communication problems and disorders in children and adults. Assume responsibility for hospital-wide implementation of evidence-based practices that support communication with vulnerable patients. Take the lead in developing communication materials, brochures, and consent forms that use simple text, large print, and picture symbols. Offer to adapt communication techniques for patients with a variety of communication, language, cultural, and literacy challenges (for examples, visit www.patientprovidercommunication.org). Establish a pool of low- and high-tech equipment that hospitalized patients may borrow (for examples, visit the Patient Provider Communication website). Identify, modify, and/or develop continuing education or in-service modules for staff. Teach health care providers in your facility and community about communication access for patients. Incorporate direct instruction about techniques (e.g., look patients in the eye, write or draw instructions for people with limited auditory comprehension, provide materials) and role-play (Garrett, Paull, & Happ, 2007). Finally, ensure that providers in your own practice settings “talk the talk” and “walk the walk” by providing a variety of services that address the communication and cognitive needs of communication-vulnerable patients in health care facilities. SLPs and audiologists are in a unique position to address the Joint Commission’s improved communication strategies for people with hearing, speech, language, and cognitive issues; individuals who speak languages other than English; and those from diverse and different cultural backgrounds. CSD professionals can take the lead in promoting effective communication between patients and hospital staff in meaningful and effective ways that ensure respect for individual differences. Roadmap Paves the Way for Better Communication The Joint Commission’s Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals is a resource to help health care providers learn to communicate with patients so that each understands the other, regardless of cultural or linguistic differences, sensory impairments, or limitations on ability to communicate via natural speech. Specifically, the document addresses ways to improve overall patient-provider communication. Examples of recommendations include: Develop language access services for patients (or providers) who speak languages other than English (including sign language) or who have limited health literacy. Translate forms and instructional materials into other languages. Respect, understand, and address different cultures, religions, and spiritual beliefs, including those of lesbian, gay, bisexual, and transgender patients. Address the needs of patients with disabilities, including those with speech, physical, or cognitive impairments, blindness/low vision, or hearing impairments. In addition, the document specifically notes that interpreters, translators, sign language interpreters, speech-language pathologists, audiologists, and church/spiritual personnel are critically needed in health care settings, and that augmentative communication strategies and assistive technologies are requisite tools for many hospitalized patients. The resource is designed for hospitals, but professionals in all settings can benefit from the information. Accreditation standards are only one of many places that call for clear, understandable communication; issues of effective patient-provider communication and improved health literacy are showing up everywhere. For example, the U.S. Department of Health and Human Services recently released the National Action Plan to Improve Health Literacy, which encourages the government, health care providers, and others to improve how health information is shared and used. The Agency for Healthcare Research and Quality has established health literacy as a universal precaution, similar to hand-washing, as a way to minimize risks to patients. The new health care reform law includes provisions regarding the use of plain language and culturally appropriate language in health-related information about insurance and other health issues. The revised Minimum Data Set 3.0, used in skilled nursing facilities to assess residents, now relies heavily on patient interviews, rather than observation, to gather important intake information. Regardless of practice setting or client population, clinicians need to improve how they—and their colleagues—communicate with patients and address cultural and linguistic differences. Besides being ethical and appropriate, patient-centered communication is also—or soon will be—a requirement under new and pending laws, regulations, and standards. References Bartlett G. R., Blais R., & Tamblyn R. (2008). Impact of patient communication problems on the risk of preventable adverse events in the acute care settings.Canadian Medical Association Journal, 178, 1555–1562. Google Scholar Garrett K. L., Happ M. B., Costello J., & Fried-Oken M. (2007). AAC in intensive care units.In Beukelman D.R., Garrett K.L., & Yorkston K.M. (Eds.). Augmentative communication strategies for adults with acute or chronic medical conditions. Baltimore, MD: Brookes Publishing Co. Google Scholar Garrett K. L., Paull B. M., & Happ M. B. (2007). Content of an Instructional AAC Program for ICU Nurses. Paper presented at the 2007 Clinical AAC Research Conference, Lexington, KY. Google Scholar The Joint Commission (2009). About Hospitals, Language and Culture: A Snapshot of the Nation. Retrieved Oct. 20, 2010, fromhttp://www.jointcommission.org/assets/1/6/hlc_paper.pdf [PDF]. Google Scholar The Joint Commission (2010a). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL: Author. Retrieved Oct. 20, 2010 fromhttp://www.jointcommission.org/Advancing_Effective_Communication_Cultural_Competence_and_Patient_and_Family_Centered_Care/. Google Scholar The Joint Commission (2010b). Sentinel Events. Retrieved on Oct. 20, 2010, fromhttp://www.jointcommission.org/sentinel_event.aspx. Google Scholar Weiss Barry D. (2007). Health literacy and patient safety: Help patients understand (second edition). American Medical Association Foundation and American Medical Association. Retrieved on Oct. 20, 2010, fromwww.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf [PDF]. Google Scholar Author Notes is president of Augmentative Communication, Inc, in Monterey, Calif., and a participant in the Augmentative and Alternative Communication-Rehabilitation Engineering Research Center (AAC-RERC), funded by the National Institute of Disability and Rehabilitation Research. Contact her at [email protected]. serves individuals with aphasia, brain injuries, complex medical conditions, and augmentative communication needs in her Pittsburgh private practice and is an adjunct faculty member at the University of Buffalo. Her research focuses on aphasia, AAC for intubated patients, and communication interventions for people with severe brain injuries. Contact her at [email protected] associate director of health care services in speech-language pathology, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetailsCited byPerspectives of the ASHA Special Interest Groups4:5 (1017-1027)31 Oct 2019Improving Patient Safety and Patient–Provider CommunicationRichard R. Hurtig, Rebecca M. Alper, Karen N. T. Bryant, Krista R. Davidson and Chelsea BilskemperPerspectives of the ASHA Special Interest Groups3:12 (99-112)1 Jan 2018The Cost of Not Addressing the Communication Barriers Faced by Hospitalized PatientsRichard R. Hurtig, Rebecca M. Alper and Benjamin BerkowitzPerspectives on Augmentative and Alternative Communication22:2 (79-90)1 Jun 2013A Demographic Study of AAC/AT Needs in Hospitalized PatientsLauren Zubow and Richard Hurtig Volume 16Issue 1January 2011 Get Permissions Add to your Mendeley library History Published in print: Jan 1, 2011 Metrics Current downloads: 1,365 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2011 American Speech-Language-Hearing AssociationLoading ...

With minorities projected to constitute a majority of the U.S. population by 2043 (Census Bureau, 2012)-and considering that the disparities in healthcare access and quality they face are well documented (CDC, 2011)-it's clear that improving care for this population will depend on understanding who they are and where gaps exist. The need to reduce disparities in care has become particularly pressing with the Affordable Care Act's (ACA) focus on value-based care and quality improvement and a growing recognition that a reformed, high-performing healthcare system must make eliminating disparities a fundamental goal. We can achieve this goal by providing the best care possible to society's most vulnerable.Low-income and other disadvantaged patients are a population that members of America's Essential Hospitals (formerly the National Association of Public Hospitals and Health Systems) know well and a key reason we have joined forces with our allies in the Equity of Care initiative. Essential hospitals-those that serve a safety net role in their communities-are uniquely positioned to help reduce healthcare disparities, as more than half our patients are racial and ethnic minorities and a majority are uninsured or qualify for Medicaid. Although our members represent just 2% of U.S. hospitals, they deliver nearly 20% of all uncompensated care (NAPH, 2012).So, collecting reliable race, ethnicity, and language (REAL) data-and viewing it as an essential component of quality improvement-has become a priority for us and our hospitals, as it should be for all healthcare providers.WHY REAL DATA IS IMPORTANTIt seems self-evident, but this tenet is often overlooked: To provide the best quality of care to your patient population, you need to know who your patients are. REAL data helps you understand your patients' varying needs and view treatments and outcomes through the lens of their rich ethnic and racial diversity. It drives better care and a better patient experience. It enhances prevention-risk of disease varies by ethnicity and race, making this information as important to the future as it is to the present. It supports culturally competent care that respects each patient's social and cultural background and aids communication to improve patient compliance and outcomes.While improving patient care and the patient experience is the primary reason for collecting REAL data, regulatory and other compliance issues also come into play- meeting federal requirements for meaningful use of health information technology, for example, and achieving patient-centered medical home certification. Collecting REAL data is always the right thing to do and often the required thing to do.WORK TO DATE, AND MOVING FORWARDIn 2011, the Equity of Care National Call to Action made collecting and using REAL data a key component of a three-pronged approach to reducing disparities that also seeks increased cultural competency training and leadership diversity (Equity of Care, 2011).Other national stakeholders over the past decade have joined the fight to improve equity, including through better collection of data. In 2001, the Institute of Medicine (lOM) report Crossing the Quality Chasm: A New Health System for the 21st Century named equity as one of six domains of quality that all healthcare organizations must address. Other important milestones along the way, particularly with respect to REAL data, include the 2009 American Recovery and Reinvestment Act and its meaningful use requirements; the 2010 ACA, with its requirement that federally funded programs collect data on race, ethnicity, primary language, disability status, and gender; the 2011 federal Action Plan to Reduce Health Disparities, which outlines ways to increase health equity, including upgrading collection and analysis of REAL data and other demographics consistent with the ACA; and The Joint Commission's 2012 patient-centered communication standards, which require hospitals to collect a patient's preferred language for both verbal and written communications regarding their care. …

Fairview Health Services is an affiliated integrated health system partnering with the University of Minnesota to establish a secure research-oriented clinical data repository that includes large numbers of clinical documents. Standardization of clinical document names and associated attributes is essential for their exchange and secondary use. The HL7/LOINC Document Ontology (DO) was developed to provide a standard representation of clinical document attributes with a multi-axis structure. In this study, we evaluated the adequacy of DO to represent documents in the clinical data repository from legacy and current EHR systems across community and academic practice sites. The results indicate that a large portion of repository data items can be mapped to the current DO ontology but that document attributes do not always link consistently with DO axes and additional values for certain axes, particularly “Setting” and “Role” are needed for better coverage. To achieve a more comprehensive representation of clinical documents, more effort on algorithms, DO value sets, and data governance over clinical document attributes is needed.

You have accessThe ASHA LeaderOn the Pulse1 Nov 2014What to Do When Your Patient Doesn’t Speak EnglishPatients are entitled to quality speech-language, swallowing and hearing services, no matter what languages they speak. Here’s how to provide them. Gennith Johnson, andMCD, CCC-SLP Claudia SaadMS, CCC-SLP Gennith Johnson Google Scholar More articles by this author , MCD, CCC-SLP and Claudia Saad Google Scholar More articles by this author , MS, CCC-SLP https://doi.org/10.1044/leader.OTP.19112014.28 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In An acute-level hospital admits a 67-year-old Haitian man who shows slurred speech and right-sided weakness. He speaks some French but is fluent in Haitian Creole, common to his region of Haiti. A nurse administers a swallow screening in the emergency room—which he fails—but the patient cannot answer standard admission questions because of the language barrier. Hospital staff consult the speech-language pathologist to complete a dysphagia evaluation, because the nurse is hesitant to administer oral medications. What should an English-speaking SLP do in this situation? Place the patient on medical hold until he can describe his problem? Proceed with a swallowing evaluation by giving the patient food and drink? Use an English communication board to explain the process of the swallow evaluation? Request a Haitian Creole interpreter to aid communication between the patient and the SLP during the evaluation? Our patient represents many people in the United States who speak a language other than English, and for whom providing quality health care can be a challenge. But SLPs and audiologists have a responsibility to provide appropriate services to people with communication or swallowing disorders who may not be proficient speakers of English. To guide practice, the Joint Commission—an accrediting organization that certifies more than 20,500 health care organizations and programs in the United States—developed a set of patient-centered communication standards for hospitals in July 2012. The standards guide clinicians on addressing all patients’ communication needs, and outline qualifications for interpreters and translators. The standards are part of a larger initiative, “Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals”, that focuses on effective communication and culturally competent care. Failure to meet these requirements could result in a loss of accreditation. According to the Joint Commission, “No longer considered to be simply a patient’s right, effective communication is now accepted as an essential component of quality care and patient safety.” Using an interpreter is the best option; ASHA’s Practice Portal provides guidance for collaborating with interpreters. You can also tap these resources to facilitate communication with non-English-speaking patients: Numerous apps and online translation sites provide immediate translation, but use them with caution: They are not always accurate. Smartphone technology can facilitate carryover and recall of strategies and techniques. For example, with a smartphone one can record spoken and video-signed clinical recommendations. Consider using Communication Access Realtime Translation (CART, or Computer Assisted Realtime) on site or remotely for patients who are deaf or hard of hearing, in addition to a sign interpreter. CART transcribes and instantaneously captions spoken language to relay messages. Let’s return to our 67-year-old Haitian patient with the language barrier. Which option is the right one according to the Joint Commission? Requesting a Haitian Creole interpreter to assist with the evaluation is the only correct answer. Hospitals accredited by the Joint Commission are required to provide language interpreting and translation services. These services can be in-person or via telephone or video. Language interpreters should demonstrate not only language proficiency, but have qualifications that are typically met through education, training and experience. Hospitals may employ language interpreters or contract out for these services; SLPs can request an interpreter through nursing or social services. Trained bilingual hospital staff may also be a viable option. Research shows that effective patient-provider communication is essential to patient safety as well as to better treatment outcomes. For more on using interpreters… ASHA Issues in Ethics: Cultural and Linguistic Competence further outlines the importance of providing culturally competent care that ensures access to services via an interpreter when needed. ASHA’s Code of Ethics also supports the use of interpreters when working with patients who do not speak English. Author Notes Gennith Johnson, MCD, CCC-SLP, is ASHA associate director of health care services. [email protected] Claudia Saad, MS, CCC-SLP, is ASHA director of multicultural education. [email protected] Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 19Issue 11November 2014 Get Permissions Add to your Mendeley library History Published in print: Nov 1, 2014 Metrics Current downloads: 8,677 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2014 American Speech-Language-Hearing AssociationLoading ...

Stakeholders will put increasing pressure on integrated health systems (IHS) for measured performance, demanding data on quality and patient satisfaction, while simultaneously pressing for lower cost. The changes to Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) and the growing importance of the National Committee on Quality Assurance (NCQA) are simply forerunners of an intensifying trend. Quality of care in particular will face increasing scrutiny. Achieving competitive targets in these areas will also require measures addressing demand and worker satisfaction. "Balanced scorecard" approaches will allow IHS and their accountable work groups to track performance on several dimensions and establish integrated goals or targets. Those with consistently good scores will be labeled "champions." Champions will support the multidimensional measures with improved decision processes. About eight major processes will be central--governance/strategic management, clinical quality, clinical organization, financial planning, planning and marketing, information services, human resources, and plant services. It is possible to map these processes to the criteria of the Joint Commission, NCQA, and Malcolm Baldrige Quality Award. The processes themselves can be measured and common weaknesses identified and corrected. Champions share some common characteristics that seem to arise from the combination of processes and measures. Among these characteristics are service line orientation, extensive partnering with other organizations, and the possibility of outsourcing organizational components.

(Excerpted from "The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition." Copyright © 2016, American Psychiatric Association. Reprinted with permission.).

This is a historical moment for launching a journal devoted to LGBT health, and it is with great enthusiasm that we do so. Recent progressive developments have created an extraordinary window of opportunity to profoundly lower the barriers to healthcare for LGBT-identified persons, to research the most important health concerns and needs of specific LGBT populations, and to train clinicians in the best practices to meet those needs. By providing a much-needed authoritative source and multidisciplinary international forum in LGBT healthcare services, education, and policy, LGBT Health aims to ensure that the current window of opportunity does not close but opens into a new era for sexual and gender minority health around the globe. LGBT Health employs the LGBT acronym as an umbrella term that is much more inclusive than apparent in its component letters. We use it to include not only lesbians, gay men, bisexual, and transgender individuals, but all of those who have experienced, or who are at risk of experiencing, discrimination and stigmatization on the basis of variation in sexual orientation, sexual identity, or gender identity. This includes, but is not limited to, those who are questioning their sexual orientation or gender identity, as well as those who identify as gender queer, asexual, or intersex. While the struggle for LGBT health equality is far from new, developments during the last 3 years, including the recent end of the Defense of Marriage Act, have laid a particularly promising foundation to support substantive and enduring change. In addition to mandating humane nondiscriminatory hospital visitation policies, the Presidential Memorandum on Hospital Visitation signed by President Obama in 2010 solicited recommendations as to how the Department of Health and Human Services (HHS) could better address the needs of the LGBT community. Shortly thereafter, HHS established an Internal LGBT Coordinating Committee to ensure that the concerns of sexual and gender minority persons would be considered throughout its activities. The LGBT health initiatives begun over the last three years by HHS are described on their website (www.hhs.gov/ secretary/about/lgbthealth_objectives_2012.html). They range from measures to address anti-LGBT discrimination, violence, and bullying, to the concerns of sexual and gender minority persons across the lifespan, including LGBT youth, who may be at risk for homelessness or suicide, and LGBT older adults, who too often bear the consequences of a lifetime of discrimination and mistreatment. They also address the current need for training the health workforce in culturally competent, patient-centered health care for sexual and gender minority persons, including funding of the National LGBT Health Education Center at Fenway by the National Institutes of Health (NIH), an agency of HHS. Every 10 years, HHS sets a health agenda for the next decade. The agenda promulgated in 2010, Healthy People 2020, is a landmark in being the first of these decade-long plans to address LGBT health concerns. The 2011 Institute of Medicine’s (IOM) Report, The Health of Lesbian, Gay, Bisexual, and Transgender People, solicited by the NIH, confirmed many of the health disparities and barriers to care long known by the LGBT health community. It also identified specific gaps in our knowledge of LGBT health, established priorities for LGBT health research, and outlined a specific agenda to advance the health of sexual and gender minority individuals and populations. On June 27, 2013, the NIH held its first ever ‘‘Listening Session,’’ seeking LGBT community input to determine the highest priorities within LGBT health research. In the same year the IOM published its report, The Joint Commission (TJC) published Advancing Effective Communication, Cultural Competence, and Patientand Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. This guide urges hospitals to create a welcoming and safe LGBT-inclusive environment and makes recommendations for doing so. These recommendations carry considerable weight since TJC certifies healthcare organizations for Medicare reimbursement, and most states also consider TJC accreditation as a condition for Medicaid reimbursement. Since 2011, TJC requires an LGBT nondiscrimination statement for accreditation, and it is currently fieldtesting additional measures of LGBT cultural competence that may factor into accreditation decisions in the future. There are also positive developments for LGBT health within the U.S. Department of Defense (DoD) and Veterans Health Administration (VHA). In the wake of the repeal of ‘‘Don’t Ask, Don’t Tell,’’ the DoD recognizes the need to research the health services needs of LGB veterans (the repeal does not benefit transgender veterans), who, though always present, had previously served invisibly, making their needs impossible to assess. The VHA has also taken amazing strides toward LGBT inclusiveness. Nearly 80% of its hospitals participated in the 2013 Healthcare Equality Index (HEI), a Human Rights Campaign–administered survey that evaluates LGBT inclusiveness. In 2013, HRC evaluated 718 healthcare facilities in all 50 states and trained over 4,000 healthcare administrators nationwide in LGBT patient-centered care. HEI respondents who meet four key

Clarifying Concepts: Cultural Humility or Competency

AN ERA OF AWAKENING began in 1999 with the publication of the Institute of Medicine's report To Err Is Human. The report turned the nation's attention to the urgent need to reduce harm in healthcare institutions. Although the report was met initially with disbelief and distrust of the data-which signaled an alarming level of harm-16 years later, healthcare generally believe that preventable harm continues to occur at unacceptable levels. For this reason, some have committed to achieving zero harm by improving their organization's safety culture, as well as by using improvement science and change management to generate sustainable gains.Across the thousands of US hospitals accredited by The Joint Commission, one observation is consistent: Effective physician leadership is a vital characteristic of high-performing healthcare organizations. Exhibit 1 shows physician engagement along the quality and safety continuum. In high-performing healthcare organizations, physicians lead, collaborate on interdisciplinary teams, and take ownership of improvement activities and outcomes. Conversely, organizations that struggle in their improvement efforts typically lack engaged physicians and effective physician leaders. In these organizations, the physicians-and at times even the physician leaders-are unable to articulate their organization's quality-improvement activities and goals (Nelson et al. 2014; Taitz, Lee, and Sequist 2012).EFFECTIVE LEADERSHIP IMPROVES QUALITY AND SAFETYEffective physician leadership is essential for transforming an organization from one that accepts harm as inevitable and makes only modest improvements each year to one that aims for zero harm and is on a path to becoming a high-reliability organization (HRO). HROs rarely, if ever, have significant accidents. These organizations manage safety hazards well, despite facing dynamic tasks, time constraints, and complex environments. In the pursuit of excellence, they constantly look for lessons in errors and close calls to reduce the risk of harm. A key to becoming an HRO is to learn from the organization's mistakes (Reason 1997; Weick and Sutcliffe 2007).The Joint Commission sets high standards for leaders. For example, according to standard LD.03.01.01 of the Comprehensive Accreditation Manual for Hospitals, leaders create and maintain a culture of safety and quality throughout the hospital (Joint Commission 2015). Standard LD 03.05.01 directs to implement changes in existing processes to improve the performance of the (Joint Commission 2015). The Joint Commission also encourages hospitals and health systems to become learning organizations, which requires a special type of leadership-one that encourages all staff to discuss safety issues openly and provides opportunities for all to participate in safety and quality initiatives. These are just a few of The Joint Commission's expectations of who intend to transform their organization into one that is highly reliable.Although improving quality and patient safety is of critical importance, it is only one of many areas in which effective physician leadership is vital. The increasing integration and growth of health systems, population health management, new payment systems, and competitive market trends are other forces that contribute to the unprecedented demand for physician leadership and physician engagement. Unfortunately, the need far exceeds the nation's supply of physician who have the critical skills required to face today's challenges.Palomar Health in Escondido, California, and ProMedica in Toledo, Ohio, are two excellent examples of healthcare organizations that are responding to this gap. These organizations represent a national movement in which healthcare organizations are taking on the responsibility of developing physician leadership programs or virtual leadership academies. Each recognized the need to improve and transform, developed a customized approach to its curriculum, and aligned physicians with the organization's goals. …

Improving health care quality and value requires increased attention to patient and family-centeredness as well as care equity. Although health literacy, language access, and cultural competency have been perceived as separate constructs. each represents a dimension of patient and family-centeredness and care equity. Developing and using integrated measures of health literacy, language access, and cultural competency could provide a viable strategy to improve patient and family-centeredness and equity in health care. While there are challenges to the development and use of integrated measures, some responsive strategies include: using more patient, family and caregiver-reported information; utilizing patient demographic data from electronic health records; and incorporating the latter elements within measures of patient experience. Integrated quality measures also create opportunities for collaborative and interdisciplinary research, and for health care delivery innovation.

Background: Many hospital stroke programs fail to meet or maintain the certification requirements of The Joint Commission (TJC) as a Primary Stroke Center (PSC) or Comprehensive Stroke Center (CSC). The most common reason is the absence of a dedicated stroke program coordinator. There are opportunities for improvement to promote stroke coordinator growth and retention. Purpose: We created The Memorial Hermann Hospital System Stroke Coordinator Alliance to combine resources, reduce workload, and support stroke coordinators in order to promote adherence to best practice and maintain TJC stroke certification. Methods: The Memorial Hermann Hospital System Stroke Coordinator Alliance was developed in 2015. It includes 14 nurses who represent 11 acute care hospitals within a large hospital system in Houston (Figure1). Four of the hospitals are CSCs, five are PSCs, and two are not certified. Monthly meetings are conducted to create standardized access to resources, stroke coordinator orientation, education, medical power plans, process improvement, and data development. Coordinator work groups, a central email and shared drive, biweekly data meetings, and a buddy system were created to reduce work load, improve electronic communication, and streamline data review procedures. A partnership was created to onboard new coordinators and to prepare for mock and real time survey visits. In 2018 data abstraction was standardized across hospitals with use of a homegrown database Stroke Program Registry (REGIS). Results: Of the 14 Stroke Coordinators in place during fiscal years 2015 - 2019, retention was 100%. A total of 19 stroke surveys were completed and recognized as successful by The Joint Commission. A total of 17,148 stroke patients were received with PSC measures averaging greater than 95% and CSC measures above 90%. Conclusion: Implementing program development support for stroke coordinators improves retention and quality care in a high volume stroke system.

Objective: We looked for factors associated with hospital readmission rates in patients diagnosed with ischemic stroke. Methods: The Stroke Program Quality Initiative developed a MIDAS™ report of all inpatient encounters to all hospitals within an integrated health system within 30 days of a stroke discharge. A focus study guided a detailed case review including demographics, index admission stroke subtype, discharge treatment and disposition, readmission diagnosis, and location. The dependent variable was readmission to the hospital within 30 days. Characteristics were compared between patients that were not readmitted versus patients that were readmitted using odds ratios (OR). Results: The analysis included 1843 stroke discharges from June 2016 to May 2018. The overall 30-day all-cause readmission rate for ischemic stroke patients was 13%; 14% at the comprehensive stroke center and 10 to 16% at the primary stroke centers. The principal diagnoses for readmission were sepsis or infection (14%), recurrent stroke (13%), and cardiovascular events (7.3). During this period, compliance with evidence-based guidelines for inpatient stroke care exceeded benchmarks. Mean time between admissions was 10 days. Of the patients that were readmitted, 30% of the patients were admitted to a different facility than their initial admission. Patients that received either tissue plasminogen activator (tPA) or mechanical thrombectomy seemed to be associated with decreased readmission rates (OR 0.5). Higher readmission rates were associated with length of stay (Overall OR 2.3; individual facilities (IF) ORs 2.1, 1.6, 2.2, 2.3, 3.5), females (Overall OR 1.3; IF ORs 1.3, 1.3, 1.3, 0.68, 0.69), age > 75 (Overall OR 1.5; IF ORs 1.8, 1.6, 1.7, 1.88, 1.7), and patients discharged to a skilled nursing facility (Overall OR 1.3; IF ORs 1.5, 0.94, 1.3, 0.98, 0.57). Widows and divorced patients had an overall OR of 1.5. Conclusion: A combination of demographic and disposition factors can consistently predict higher readmission rates amongst ischemic stroke patients within a large hospital system that shares a cohesive stroke care policy amongst the individual facilities, whereas acute treatments with either tPA or mechanical thrombectomy were protective.

The U.S. Census Bureau projects that by 2050, non-Hispanic whites will be in the numerical minority. This rapid diversification requires healthcare organizations to pay closer attention to cross-cultural issues if they are to meet the healthcare needs of the nation and continue to maintain a high standard of care. Although scorecards and benchmarking are widely used to gauge healthcare organizations' performance in various areas, these tools have been underused in relation to cultural preparedness or initiatives. The likely reason for this is the lack of a validated tool specifically designed to examine cultural competency. Existing validated cultural competency instruments evaluate individuals, not organizations. In this article, we discuss a study to validate the Cultural Competency Organizational Assessment--360 or the COA360, an instrument designed to appraise a healthcare organization's cultural competence. The Office of Minority Health and the Joint Commission have each developed standards for measuring the cultural competency of organizations. The COA360 is designed to assess adherence to both of these sets of standards. For this validation study, we enlisted a panel of national experts. The panel rated each dimension of the COA360, and the combination of items for each of the scale's 14 dimensions was rated above 4.13 (on 5-point scale). Our conclusion points to the validity of the COA360. As such, it is a valuable tool not only for assessing a healthcare organization's cultural readiness but also for benchmarking its progress in addressing cultural and diversity issues.