Hello, my name is Darci Graves, and I am a senior member of the Health Determinants & Disparities Practice at SRA International, Inc. We do work for the Office of Minority Health at the U.S. Department of Health and Human Services. One of our projects for the Office of Minority Health is on the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care . also called the National CLAS Standards. I.m very pleased to be with you today to talk about the National CLAS Standards, Health Literacy, and effective Communication. Today, we.re going to talk about: What is communication? Why should we focus on it? What is CLAS, and what are the intersections of CLAS, health literacy, and communication? And finally, What are the National CLAS Standards, and how can you use them to improve communication, address health literacy, and, ultimately, improve quality of care?

As you know, communication is at the core of our health care experiences. When I say communication, I.m referring to spoken, written, signed, and multimedia communication. We.ve all seen how communication can influence a health care encounter for better or worse. In fact, the Joint Commission reports that communication problems are the most frequent root cause of serious adverse event seen in its Sentinel Event Database. As we.ve been discussing today, health literacy levels are a critical factor in communication in health care. Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. 9 out of 10 adults have trouble understanding health information, and this can cause poorer health outcomes for a variety of reasons. In addition, the cultural and linguistic diversity in this country presents communication challenges. Every health care encounter is a cross-cultural interaction: you should consider not only the patient.s culture, but your culture as a health professional and the culture of your organization.

It.s important to keep this in mind as you seek to respond effectively to the health needs of diverse communities in your service area. Let.s also remember that about 1 out of every 12 people in the United States speak English less than very well, and this language barrier also compromises patient safety. Health care professionals and organizations are learning how to take steps to communicate well with culturally and linguistically diverse populations and individuals with varying degrees of health literacy.

So, if communication is so important, what exactly does good communication look like? The Joint Commission in their Roadmap for Hospitals defines effective communication as: The successful joint establishment of meaning wherein patients and health care providers exchange information, enabling patients to participate actively in their care, and ensuring that the responsibilities of both patients and providers are understood. To be truly effective, communication requires a two-way process in which messages are negotiated until the information is correctly understood by both parties. More specifically, good communication means that: a provider understands and integrates the information gleaned from a patient, and a patient comprehends messages from a provider.

Why should we focus on improving communication? This diagram shows us what factors influence communication, and what problems can arise from bad communication. This diagram is adapted from the HHS Agency for Healthcare Research and Quality. Language, culture, and health literacy levels affect communication between a health professional and a patient. When there are differences in health literacy levels, language abilities, and cultures, it.s likely that communication will suffer. Communication problems, in turn, can lead to patient safety issues, medical errors, readmissions, and poorer health outcomes.

On top of that, poor communication can also cost health systems a lot of money. You have seen these consequences firsthand, but I.d like to discuss what this has to do with CLAS . culturally and linguistically appropriate services. What are the intersections of CLAS, health literacy, and communication? CLAS stands for culturally and linguistically appropriate services. CLAS is defined as services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs and employed by all members of an organization (regardless of size) at every point of contact. Here, I.d like to point out again that every health encounter is a cross-cultural encounter. Each health facility, health professional, and patient brings their culture to the encounter. CLAS helps us navigate these differences so communication is more meaningful and effective. We.ll explore this definition more closely, but first, let.s discuss why CLAS matters. Culturally and linguistically appropriate services matter for many reasons. Some of these reasons have to do with numbers and the bottom line, and this is the business case for CLAS. Other reasons have to do with issues of equality and humanity, and this is the social justice case for CLAS.

The business case for CLAS asserts that culturally and linguistically appropriate services help a health organization.s bottom line and competitiveness in the marketplace. I.ll highlight a couple of these reasons here: Litigation: Research shows that good communication helps avoid cases of malpractice due to diagnostic and treatment errors, which can cost millions of dollars in liability or malpractice claims. Attorneys estimate that a clinician.s communication style and attitude are major factors in 75% of malpractice suits. Culturally and linguistically appropriate services can reduce the possibility of such errors. Accreditation: Accrediting bodies such as The Joint Commission and the National Committee for Quality Assurance have established accreditation standards that focus on improving communication, cultural competency, patient-centered care, and the provision of language assistance services . and, specifically, for patient education information to be written in a way that patients understand.

Implementing CLAS helps make sure you.re meeting these accreditation requirements. Cost of Disparities: Research shows that eliminating health disparities for minorities would have reduced direct medical care expenditures by $230 billion between 2003 and 2006. For example, about 30% of direct medical care expenditures for African Americans, Asians, and Latinos were excess costs due to inequalities. In addition, limited literacy is estimated to cost the U.S. at least $50 billion per year. For example, one state determined that the average annual healthcare costs for all Medicaid enrollees was $2,800 . but it was over $10,000 for those with limited literacy. I.d also like to mention legislation as an important incentive for implementing culturally and linguistically appropriate services. Most significantly, the Affordable Care Act contains several provisions related to culturally and linguistically appropriate services. In addition, Title VI of the Civil Rights Act of 1964 details some requirements related to the provision of language access services by organizations receiving Federal funds. Furthermore, several states have passed legislation related to cultural and linguistic competency.

On the other hand, the social justice case for CLAS is based on the premise that CLAS can help reduce healthcare disparities. As Secretary Sebelius put it: .Minority and low-income Americans are more likely to be sick, and less likely to get the care they need.. There is a huge amount of literature that exposes the many disparities experienced by diverse communities. CLAS is an important way to help eliminate health care disparities because CLAS helps overcome cultural and linguistic barriers, which can lead to miscommunications and therefore poorer quality of care.

Therefore, an organization may choose to implement CLAS because it has a mission to promote equity and/or reduce health disparities and/or improve quality of care. In terms of demographics, the U.S. is becoming more culturally and linguistically diverse, but the healthcare workforce is not diversifying as quickly. This is widening the cultural and linguistic differences between health professionals and patients, making miscommunications more likely. Thus, an organization may choose to implement CLAS to better respond to changing demographics in its service area.

Now that we.ve explored why CLAS matters, let.s take a closer look at one part of this definition: preferred languages, health literacy levels, and communication needs. The .Linguistically appropriate. part of CLAS actually has to do with communication in a broad sense, including language(s) spoken, written, or signed; dialects or regional variants; literacy levels; and other related communication needs. What this means is that, ultimately, CLAS helps us de-jargonize the health system and healthcare encounters so everyone involved is on the same page. There.s often a disconnect between the communication style, language ability, and literacy level of a health professional and a patient. This has to do with differences in communication skills of lay people and health professionals, as well as differences in their knowledge of the health topics being discussed. It also has to do with cultural barriers, and sometimes there exists a language barrier also. It.s important to remember that even highly literate people report difficulty understanding health information. Someone with limited health literacy may have trouble:Navigating the healthcare system, including filling out complex forms and locating providers and services, Sharing personal information, such as health history, with providers, Engaging in self-care and chronic-disease management

Let.s also keep in mind that health literacy includes numeracy skills, which includes the ability to understand numerical and mathematical concepts, like calculations, probability, and risk. This will impact a person.s ability to, for example, calculate blood sugar levels, measure medications, and understand nutrition labels. You can.t tell someone.s level of health literacy by looking. But, when you implement culturally and linguistically appropriate services throughout a system, you take into account health literacy and other communication issues across the board, which helps you bridge these gaps. The second aspect of this definition I.d like to highlight is that CLAS should be employed by all members of an organization at every point of contact. What does it look like to consider health literacy and communication at every point of contact? Let.s consider an example.

Tanaka drove into the hospital campus but could not find a sign to identify the location of outpatient services. He parked in the visitor garage and walked up three flights of steps to the skywalk into the hospital. Once there, he could not find the elevator and walked down three flights to the lobby. Now quite out of breath, he arrived at the registration desk. The registration clerk provided Mr. Tanaka with forms, in English. It took him more than 20 minutes to complete them as best he could. The clerk told Mr. Tanaka how to get to the x-ray waiting area, but he did not understand much of what she said. He wandered around the hospital, lost, for almost 30 minutes. A technician finally noticed that Mr. Tanaka had passed the same reception area several times and directed him down the hall to x-ray. The x-ray technician, who did not speak Japanese, explained the procedure to Mr. Tanaka and had no idea whether he understood what she was telling him.

When the radiologist determined that Mr. Tanaka had pneumonia, he instructed Mr. Tanaka, in English, both orally and in writing, to see his doctor immediately. Mr. Tanaka left the x-ray department, unsure about how to get back to his car. He knew that he was to see his doctor again but did not understand the radiologist.s instruction that he should do so immediately. After walking another 15 minutes, Mr. Tanaka, now exhausted, drove home for a nap.

Now, I.d like to share with you a framework for thinking about and implementing culturally and linguistically appropriate services, which are the National CLAS Standards. We.ll go over how you can use the National CLAS Standards as a tool to promote and implement strategies for effective communication. The National CLAS Standards were first developed by the HHS Office of Minority Health in 2000. In 2010, the Office of Minority Health launched an initiative to update the Standards, which incorporated public comment, a literature review, and ongoing consultations with an advisory committee comprised of 36 experts representing a variety of disciplines and organizations. In April of this year, we were very excited to released the enhanced National CLAS Standards at the White House. There are 15 Standards, each of which is an action step that guides professionals and organizations in their implementation of culturally and linguistically appropriate services. Let me walk you through the concepts on which the Standards are founded, and then I.ll discuss the Standards themselves.

The Standards define .culture. to encompass racial, ethnic, and linguistic groups but also geographical, religious and spiritual, biological, and sociological characteristics. Culture is defined as the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics. Culture is dynamic in nature, and individuals may identify with multiple cultures over the course of their lifetimes. This definition attempts to reflect the complex nature of culture, as well as the various ways in which culture has been defined and studied across multiple disciplines. How people experience their health and define their well-being has a lot to due with their cultural identity. This definition of health reflects the fact that many aspects of health influence one.s well-being. The definition of .health. includes physical, mental, social, and spiritual well-being. This broad definition, then, encompasses medicine, behavioral health, mental health, public health, social work, community health centers, emergency health services, and more. Because of this, the audience of the Standards is .health and health care organizations,. which are any public or private institutions addressing individual or community health and well-being. The Standards are designed for a broad array of disciplines and fields, and this acknowledges the role of social determinants in one.s health, which are the conditions in which we are born, grow, live, work, and age.

What is the purpose of the National CLAS Standards?

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities. The Standards establish a blueprint for health and health care organizations to implement and provide culturally and linguistically appropriate services. The National CLAS Standards are comprised of 15 Standards that inform and facilitate the implementation of culturally and linguistically appropriate services. [guidelines/action steps] They are intended to be used together, and they mutually reinforce one another. In fact, as you see on the slide, there is a Principal Standard (#1) that serves as the foundation for all the other Standards. The rest of the Standards are structured into three themes: governance, leadership, and workforce, Communication and language assistance, Engagement, continuous improvement, and accountability. The Principal Standard, shown here, frames the essential goal of all of the Standards. Conceptually, if the other 14 Standards are adopted, implemented, and maintained, then the Principal Standard will be achieved.

Providing effective, equitable, understandable, and respectful quality care and services helps: create a safe and welcoming environment at every point of contact that fosters appreciation of the diversity of individuals and provides patient- and family-centered care, meet communication needs so that individuals understand the health care and services they are receiving, can participate effectively in their own care, and make informed decisions, eliminate discrimination and disparities

Governance, Leadership, and Workforce emphasizes that implementing CLAS is the responsibility of the entire system. Implementing CLAS really requires the investment, support, and training of all individuals within an organization. The impetus for implementing CLAS can, and often, comes from the bottom up. However, an organization.s leadership shapes the culture of the organization through its priorities, expectations, and the behavior that it models. Therefore, the impetus for implementing CLAS should also come from the top down. You may have read or heard about the story of Lia Lee in The Spirit Catches You and You Fall Down. Who here is familiar with Lia? Lia was a young Hmong child diagnosed with severe epilepsy as a baby, and from the beginning, ongoing cultural conflicts and misunderstandings obstructed her treatment. There were miscommunications at every step of the way. For example, her parents refused to give her certain medicines due to mistrust and misunderstandings. In addition, her doctors were reluctant to learn more about Hmong culture. Lia.s health team didn.t communicate with her family in a culturally and linguistically appropriate manner. Therefore, the health team and Lia.s parents were rarely on the same page regarding Lia.s health problems and treatment options. Lia's condition eventually worsened until she slipped into a coma at age 4. She passed away at age 30 in 2012. Although Lia.s case is hopefully an extreme example, it illustrates the importance of establishing respect, trust, and good communication throughout an entire health system, from top to bottom.

The Standards teach us that implementing CLAS at every point of contact is a critical way to improve quality of care and avoid this type of situation. Standard 2 underscores that CLAS must permeate every aspect of the organization, from the top down and from the bottom up. We know that leadership, in large part, determines whether the organization.s culture will embody quality, safety, and CLAS. Standard 2 will help organizations: provide adequate resources to support and sustain CLAS initiatives, model an appreciation and respect for diversity, inclusiveness, and all beliefs and practices

Standard 3 has to do with recruiting, promoting, and supporting a diverse governance, leadership, and workforce. It will help organizations: create an environment in which culturally diverse individuals feel welcomed and valued, infuse multicultural perspectives into planning, design, and implementation of CLAS. Standard 4 has to do with educating and training governance, leadership, and workforce. It will help organizations: prepare and support a workforce that works well with diverse populations

Communication and Language Assistance provides guidance on how to effectively meet patients. communication needs, including sign language, braille, oral interpretation, and written translation. The standards in this theme will help organizations comply with requirements such as Title VI of the Civil Rights Act of 1964; the Americans with Disabilities Act of 1990; and other relevant federal, state, and local requirements to which they may need to adhere. Poor communication can have tragic consequences. For example, in the case of Willie Ramirez, the misinterpretation of a single word led to a case of potentially preventable quadriplegia. Willie was a Spanish-speaking 18-year-old, and one day he had stumbled into his girlfriend's home and told her he was .intoxicado,. and then he collapsed. He was taken to the hospital in a comatose state. When the girlfriend and her mother repeated the term, the non.Spanish-speaking paramedics took it to mean .intoxicated.; the intended meaning in Cuban Spanish was .nauseated.. After more than 36 hours in the hospital being worked on for a drug overdose, Willie was reevaluated and given a diagnosis of intracerebellar hemorrhage. An emergency operation followed; however, at this point, his hemorrhage had been bleeding for too long, and the brain damage left Willie a quadriplegic.

The hospital ended up paying a $71 million malpractice settlement. Standard 5 has to do with offering communication and language assistance. It will help organizations: make sure that individuals with limited English proficiency and/or other communication needs have equitable access to health services, improve patient safety and reduce medical error related to miscommunication. Standard 6 has to do with informing individuals of the availability of language assistance services. It will help organizations:inform individuals with limited English proficiency, in their preferred language, that language services are readily available at no cost to them to facilitate access to language services

Standard 7 has to do with ensuring the competence of individuals providing language assistance. It will help organizations: provide accurate and effective communication between individuals and providers, empower individuals to negotiate and advocate for important services via effective and accurate communication with health and health care staff.

Standard 8 has to do with providing easy-to-understand materials and signage. This is especially where health literacy comes in. It will help organizations: make sure that readers of other languages and individuals with various health literacy levels are able to understand and access care and services. The materials referred to include administrative and legal documents, clinical information, and materials related to education, health prevention and promotion, and outreach. Materials should use appropriate graphics, user-friendly design, focus on actionable information, and avoid jargon. Engagement, Continuous Improvement, and Accountability underscores the importance of establishing both individual and organizational responsibility for implementing CLAS. Effective delivery of CLAS demands actions across an organization. This theme focuses on the supports necessary for adoption, implementation, and maintenance of culturally and linguistically appropriate policies and services regardless of one.s role within an organization or practice

All individuals are accountable for upholding the values and intent of the National CLAS Standards. An study published in the Journal of Healthcare Management described a good example of a health organization using the CLAS principles of this theme to improve communication and care. A hospital discovered that Latino mothers were making frequent emergency department visits for their children's earaches because they did not understand how to take the children's temperature. The hospital's response was to develop kits that included a thermometer and easy-to-follow instructions. The CEO noted, "Instead of spending $400 an hour [in the ED] we give them a $3 kit.. This illustrates the benefits of engaging your patient populations in order to better understand . and be accountable to . their needs. And implementing a solution to a problem that was identified. Standard 9 has to do with infusing CLAS throughout the organization.s planning and operations. It will help organizations: make CLAS central to the organization.s service, administrative, and supportive functions,link CLAS to other organizational activities, including policy, procedures, and decision-making related to outcomes accountability. Standard 10 has to do with conducting organizational assessments. It will help organizations:assess performance and monitor progress in implementing the National CLAS Standards, obtain information about the organization and the people it serves, which can be used to tailor and improve services
Standard 11 has to do with collecting and maintaining demographic data. It will help organizations: accurately identify population groups within a service area, monitor individual needs, access, utilization, quality of care, and outcome patterns. Standard 12 has to do with conducting assessments of community health assets and needs. It will help organizations: determine the service assets and needs of the populations in the service areas (needs assessment), identify all of the services available and not available to the populations in the service areas (resource inventory and gaps analysis)determine what services to provide and how to implement them, based on the results of the community assessment.

Standard 13 has to do with partnering with the community. It will help organizations: provide responsive and appropriate service delivery to a community, empower members of the community in becoming active participants in the health and health care process. For example, Holy Cross Hospital in Maryland re-designed its maternity suites to be culturally appropriate to its patient population, which actually increased its market share because the number of deliveries per year increased from 7,000 to 9,000. Standard 14 has to do with creating conflict and grievance resolution processes that are culturally and linguistically appropriate. It will help organizations: facilitate open and transparent two-way communication and feedback mechanisms between individuals and organizations, anticipate, identify, and respond to cross-cultural needs. Standard 15 has to do with communicating the organization.s progress. It will help organizations: convey information to intended audiences about efforts and accomplishments in meeting the National CLAS Standards, build and sustain communication on CLAS priorities and foster trust between the community and the service setting. Now that you know what the National CLAS Standards are, where can you find out more information about how to use them?

A Blueprint for Advancing and Sustaining CLAS Policy and Practice . simply referred to as The Blueprint . is a new guidance document for the National CLAS Standards that discusses implementation strategies for each Standard. The Blueprint explains the case for CLAS, the enhancements, and the concepts found throughout the Standards. In addition, it lists many resources found online for additional information and guidance. Join our community, join our conversation by visiting Think Cultural Health

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