Organizational journeys to CLAS, Part II: Challenges and successes for implementation

AtlantiCare is an integrated healthcare system dedicated to transforming healthcare at the regional level by providing higher quality health and wellness services. AtlantiCare includes AtlantiCare Regional Medical Center, the AtlantiCare Foundation, AtlantiCare Health Services, AtlantiCare Health Plans and AtlantiCare Behavioral Health. AtlantiCare also has a Center for Community Health that designs programs and services to address public health issues and concerns. The region’s largest healthcare organization and largest non-casino employer, AtlantiCare’s 4,585 employees and more than 550 physicians serve the community at more than 60 locations. AtlantiCare and its business units are governed by boards comprised of more than 70 volunteer community leaders.
The Challenge
AtlantiCare’s primary service area, serves a population of 25.5% that speaks a language other than English. In “our backyard”, Atlantic City, we serve a population of 38.4% that speaks a language other than English, 23.7% of that population speaking Spanish. We encounter over 70 different languages a month, most frequently are Spanish, Bengali, Mandarin, Cantonese, Guajarati, Hindi, Vietnamese, Haitian Creole, and Arabic. Atlantic County serves a minority population of 22.3% and a Hispanic population of 15.6%. In our dominant service areas such as Atlantic City, Pleasantville, and Pomona, AtlantiCare serves a minority population +55% and a Hispanic population around 23%.
Planning: It all began as an Initiative
The C.L.A.S Initiative began in 2003 with the objectives to (1) build the capacity for delivering excellent services to all people regardless of race, ethnicity, language, and culture (2) comply with regulations/ laws and (3) engage our community in partnerships around health and wellness. The Initiative staffed one FTE and a limited budget.
Senior Leadership (SL) Support: The C.L.A.S Standards were used as a blueprint to frame the work and presented to the SL. A committee of SL and management were pulled together to assess the needs and opportunities within the organization. 
Outcomes: Immediate integration of telephonic interpreter services in 2004 throughout AtlantiCare, at all points of access. Standard data collection fields for patient race, ethnicity, and language were implemented at all registration points of service.
Community Partnerships: 2004-2006 the CLAS Initiative focused on community engagement and established relationships with community leaders to engage them in being advocates for health and wellness in their communities. AtlantiCare partnered with community groups such as the Hispanic Alliance of Atlantic County to form the Latino Coalition, which brought together community members to discuss health issues, culture within health care, and AtlantiCare services. Also, with the Hispanic Alliance and NAACP, AtlantiCare built programs to recruit and enhance employment opportunities and the diversity of the candidates.
Lessons Learned: Community Partnerships will enhance the services that you will provide. Partnerships build company image, trust, respect, and opportunities in many areas.
C.L.A.S Initiative transitions to Cross Cultural Services
In 2006, we brought a strong focus back inside the organization. The goal was to integrate the work with internal partners, departments, and business units.
CLAS Committees: Action Committees were formed to focus on (1) Language Services (2) Cultural Competency Education (3) Organizational Structure and alignment with the system strategic objectives. These committees were chaired by SL’s within the organization, and reported to the Strategic SL Team.
Lessons Learned: Defining the work was at times challenging. Having the support of SL and having the right people involved at the right time proved instrumental in our success. We transitioned from a committee framework to support service framework and found by partnering with the key players, such as human resources, medical affairs, and education, opportunities were able to be quickly identified and actions plans created and implemented.
Medical Interpreter Pilot:  July 2007, through the CLAS Initiative the Center for Childbirth, ARMC Mainland Campus, was identified to pilot Interpreter Services for 5 months and test for process and measurement. With rapid quality improvement cycles and “small tests of change” we were able to show increases in customer satisfaction, employee satisfaction, and cost savings.
Lessons Learned: Implementing the pilot involved collaborations between services, departments, and staff. We raised awareness around the need and gained staff support! Automatic champions for the work.
Outcomes: Through successful completion of the pilot, AtlantiCare approved 2 FTE Medical Interpreters creating the foundation for Cross Cultural Services. We started small with one interpreter at each Medical Center, but planned big, with onsite interpreters in multiple languages eventually being available at all AtlantiCare locations.
Partnering with Service Lines: September 2007, The Heart Institute at ARMC Mainland Campus, obtained grant funding in partnership with Cross Cultural Services to identify disparities in the African American and Latino Populations for Heart Failure.
Outcomes: This grant opened communication to more physicians, nurses, management, and staff. The CEO of AtlantiCare attends learning network sessions for the grant, and has a visible presence in the project.
Leveraging Resources: In 2007-2008, AtlantiCare partnered with NJHA to train bilingual staff members on Interpreter Standards of Practice, Code of Ethics, and Interpreter Skills. The bilingual staff that participated, helps deploy information on Language Services, is part of the Cross Cultural Services family, and they’re champions for the work!
Implementing Cross Cultural Services
Cross Cultural Services staffs 4 FTEs: Supervisor, Coordinator, and 2 Medical Interpreters. With limited staff, Cross Cultural Services offers system wide and community support services and programs.
Outcomes: By developing a team approach to implementation, we are able to leverage human and fiscal resources, and continue to enhance our services and programs.
The Business Case: Providing the business case for Cross Cultural Services is imperative to sustain and enhance the services that are offered. Find best practices, call the experts, and network!
Lessons Learned: Let the experts tell you! January 2008, AtlantiCare was fortunate to have Dr. Joseph Betancourt and Dr. Alex Green from Massachusetts General speak to the SLT. Leadership gained more understanding of the rationale behind integrating CLAS, and has dedicated more time, resources, strategic planning, and support to program implementation.
Strategic Alignment: Find measurements that your system is using- quality, accreditation, or patient safety criteria can all be aligned with integrating culturally and linguistically appropriate services. AtlantiCare utilizes Magnet, JCAHO, and the Malcolm Baldrige criteria to align Cross Cultural Services and programs. Each of these recognizes patient-centered care, quality, patient safety, language services, and customer engagement as their criteria.
Measurements: Evaluate program performance quarterly, annually, and over time. Indicators were identified for each service; and measurements align with the strategic goals of the system.
Moving Forward

In this field, we need to constantly be innovative, adapt to change, show flexibility, and utilize our resources! We seek to enhance the use of technology and equipment within Language Services. We would like partner with additional Business Units, such as the Cancer Center and Health Plans, and enhance their services to meet the needs of their diverse customers. We are revising system policies, procedures, and processes to include culture and language services and expectations. Finally, we plan to stratify our clinical data by race, ethnicity, language, and gender as part of our quality improvement processes.