When a patient walks into Integrity Urgent Care Clinics, he’s sure to be understood, and he’s sure to leave with a clear understanding of what happened during his visit and what he can expect after discharge. That’s because the Colorado-based centers are committed to delivering what accreditation body The Joint Commission refers to as CLAS, or Culturally and Linguistically Appropriate Services.
According to CEO Lori Japp, PA-C, one of the ways Integrity Urgent Care Clinics delivers CLAS is through providing interpreting and translation services. “Anytime a patient comes in where English is not their language of choice, we use a translation service,” she says. For patients that are hearing impaired, “we have a group in town that will come in and do sign language.”
According to the U.S. Census Bureau, 19.2 million people between the ages of 16 and 64 have limited English proficiency, which amounts to nearly 10 percent of U.S. adults. That’s why the very first patient interaction should start with an assessment of communication practices. Japp says that, sometimes, patients will “look at you with a blank stare or a look of frustration, which will clue you in that there is some type of language barrier.” If the language can’t be readily identified, a visual language card can help. “Then call interpretation services,” says Japp.
In Japp’s experience, “The strong majority of folks who don’t speak English will bring someone with them” who does speak the language. But she warns against relying on a patient’s friend or family member – or even a staff member – to relay information. “With bilingual staff members, we have to make sure they’ve gone through training and have passed an internal audit process to make sure they’re able to translate medical terminology appropriately,” she says.
Dr. Christina Cordero, associate project director for The Joint Commission, echoes that sentiment, saying that it’s critical for urgent care centers to develop a system for language services, whether it is a staff interpreter or phone or video services. “You don’t want to rely on family and friends, untrained or unqualified individuals, to perform interpreting services on behalf of the organization,” she says.
Cordero does admit that it can be difficult to find the balance between implementing CLAS and maintaining a patient-centered approach to care. “Some patients decline using translation services, and would rather use a family member,” she says. While some organizations ask patients to sign a waiver, Cordero says it’s important for the urgent care center to have its own interpreter present in order to mitigate risk. “Have both people in the room to make sure the family member or friend is accurately interpreting,” she advises.
More than Translation
Providing patients with the proper translation or interpretation services is crucial, but the spoken word is only one aspect of CLAS. For some patients, the written word can present a barrier to healthcare. According to the U.S. Department of Education, 14 percent of U.S. adults can’t read, and 21 percent read below a fifth grade level. And the National Assessment of Health Literacy found that only 12 percent of adults have health literacy proficiency.
A patient’s literacy-related clues might include stating that she’s forgotten her glasses or asking to take paperwork home and return later. One approach is to implement a policy where staff asks each patient if he or she would like help with paperwork, while another is to discreetly inquire whether a specific patient needs assistance.
Integrity Urgent Care Clinics also places an emphasis on accessible written materials. “Our informed consents are in several different languages,” Japp says. “And we try and structure all of our discharge instructions for a fifth grade reading level. We avoid a lot of medical terminology that people aren’t familiar with.”
Japp says that the discharge process is critical. At Integrity Urgent Care Clinics, the provider “closes the loop,” reviewing discharge instructions with the patient and fielding any questions the patient has. “Then the medical assistant will go back in,” Japp says. “She takes the printed discharge papers and goes over the diagnosis, treatment plan, and medications again.”
Patients who don’t speak English and those who don’t have health literacy proficiency aren’t the only people who should be accommodated by CLAS. Some patients may have cultural- or religion-based modesty issues that might make it inappropriate for providers of a different gender, or those who are older or younger than the patient, to deliver care. Other patients may have dietary restrictions that impact what types of medications can be prescribed.
The Joint Commission advises those in a healthcare setting to ask patients about other needs that might affect care, and then work to accommodate those.
Walking the Walk
Talking the talk (in the correct language) is one aspect of CLAS, but walking the walk is another. In order to pave the way for appropriate communication at every touch point of a patient’s visit, management needs to clearly demonstrate its commitment to CLAS. This means setting policy, conducting trainings, and providing resources to ensure that patients’ cultural and linguistic needs are met. For example, Japp says, “Leadership needs to ensure that their ancillary staff knows that it’s standard protocol to call interpretation services.”
Leadership extends to an urgent care center’s hiring practices. According to The Joint Commission’s standards, ambulatory care center leadership and staff should reflect the cultural and linguistic diversity of the population it serves. Then they should be trained. When it comes to translation services, for example, Cordero says staff should “know how to get the services they need,” including information about how to call the appropriate person and any relevant access codes.
As for the cost of providing CLAS, the buck stops with the urgent care center. “It’s not something that we bill the patient or the insurance company for,” says Japp. “I’ve seen where team members are afraid to call the translation service because they know it costs more money,” Japp says, “but it’s our responsibility to deliver safe, compassionate care.”
Lori Japp, PA-C, CEO of Integrity Urgent Care Clinics, identifies five steps that urgent care centers can take to deliver Culturally and Linguistically Appropriate Services (CLAS):
- Assess communication practices. Review everything from the front desk check-in process to the discharge process, and identify any gaps. “Look at each point of contact as a risk assessment,” Japp says. She suggests analyzing the greatest communication gaps and assigning numbers according to risk. Work on the highest numbers first.
- Research other plans. “The Joint Commission’s Roadmap for Hospitals is a great tool and can be adapted to an urgent care setting very easily,” says Japp. [see link below]
- Research local services. “Look at the interpretation services and sign language services in your area,” suggest Japp. “Develop a protocol to determine whether your own team members have qualifications to act as interpreters.”
- Set expectations. “Develop your own workflow and set of expectations for each point of contact,” says Japp. “Asking team members for their input helps them buy into the process.”
- Monitor and evaluate. Ask for feedback from the staff and feedback from patients. “Always focus on continuous improvement,” says Japp.
The Joint Commission has a number of resources that urgent care centers can adapt in order to improve their patient communication practices. The Joint Commission’s guides and roadmaps can be used as self-assessment tools and educational resources. They include:
A Crosswalk of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care to The Joint Commission Ambulatory Health Care Accreditation Standards, downloadable from http://www.jointcommission.org/assets/1/6/Crosswalk_CLAS_AHC_20141110.pdf
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. While much of the material is not applicable to urgent care centers, the roadmap can act as a springboard to create an urgent care center’s CLAS plan. Appendix E contains a wealth of resources for culturally and linguistically appropriate guidance and material. It is downloadable from http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf
Advancing Effective Communication, Cultural Competence, and Patient- and Family- Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community, downloadable from http://www.jointcommission.org/assets/1/18/LGBTFieldGuide_WEB_LINKED_VER.pdf