Sixth National Conference on Quality Health Care for Culturally Diverse Populations: Peer-to-Peer Practice Advancement Sessions Working to improve language services in California public hospitals: An assessment of organizational readiness to engage

A-4 Organizational journeys to CLAS, Part I: Readiness to engage

Working to improve language services in California public hospitals: An assessment of organizational readiness to engage
Monday, September 22, 2008: 10:45 AM-12:15 PM, Minn Marriott, 6th Floor - St. Croix I
Authors:  Julie Yonek*, Alan Cohen, Joseph Restuccia, Kevin Van Dyke, and Romana Hasnain-Wynia

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Background:  A consistent body of evidence documents the extent of language barriers in health care.  Health care providers report language difficulties and inadequate funding of language services as major barriers to non-English speaking patients’ access to high-quality health care.  As racial and ethnic diversity in the U.S. continues to increase, so does the demand for the provision of appropriate and effective language services.  This issue is particularly relevant in California given its very diverse population. According to the California Association of Public Hospitals and Health Systems (CAPH), approximately 40 percent of California’s residents speak a language other than English as their primary language and 50% of public hospital patients are limited-English proficient.

Since 2002, the California Health Care Safety Net Institute (SNI), the research and education affiliate of CAPH has implemented a series of initiatives focused on promoting and improving language access in California public hospitals. These initiatives include educational forums, the development of Straight Talk: Model Hospital Policies and Procedures on Language Access, the LEAD program, and Advancing Public Hospitals Along the Language Access Continuum.  In 2006, The California Endowment commissioned the Health Research and Educational Trust, an affiliate of the American Hospital Association, to evaluate strategies and SNI initiatives to promote language access improvement in California public hospitals.  The evaluation team consisted of researchers from the Health Research and Educational Trust (HRET), Boston University’s Health Policy Institute (HPI), and Northwestern University (NU).  Collectively the team has extensive experience conducting evaluation projects with culturally diverse communities involving multiple stakeholders.

Evaluation Objective: The objective of the evaluation is to identify strategies that engage hospitals in promoting systems-level change and to assess the impact of the work by California public hospitals to improve language access for Californians. We measured the hospitals’ readiness to engage (RTE) in improving language services and highlighted system-level barriers and facilitators.

Methods:  The target population was CAPH member hospitals. 17 of 20 hospitals were selected for the evaluation. 12 agreed to participate and 5 declined.  Of the 5 that declined, 2 closed down and 3 refused to participate.  Not having the time or resources to coordinate a site visit was cited as a reason for refusal by all 3 hospitals.  We conducted site visits to the remaining 12 hospitals in 2007.  Using a qualitative approach to data collection, we conducted key informant interviews with hospital leaders, operational managers, clinicians, and other staff using a semi-structured protocol to obtain perspectives regarding:

  1. mission and organizational culture
  2. commitment of  leaders to promote and improve language access
  3. current approaches to providing language services
  4. facilitators and barriers to providing effective language services
  5. staff sensitivity to and knowledge of the language needs of patient populations; and
  6. strategies to improve language access and quality of language services.

A total of 186 staff members were interviewed across all 12 hospitals, for an average of 15.5 staff per hospital (range: 9 – 23).

To gauge the extent to which a hospital had engaged or was prepared to engage in language services improvement, we developed a Readiness to Engage (RTE) instrument with 17 specific measures based upon seven key elements.  The 7 elements, all focused on language services, include:

  1. Commitment of top leaders (senior managers and Board of Trustees) to language service improvement;
  2. Sense of urgency/importance among staff members to provide language services;
  3. Defined goals and strategies (e.g., written plans, policies and procedures) for providing language services; 
  4. Methods, frequency and extent of communication to staff members regarding language service goals and strategy; 
  5. Adequate infrastructure for provision of language services (i.e., funding, nature and availability of competent interpreter services, response time, collection and reporting of patient data regarding requests for and use of language services); 
  6. Spread/diffusion of language services across hospital units (e.g., emergency department, admissions office, clinics, etc.); and 
  7. Sustainability of services.

Each of the 17 measures was scored on a scale of 0 to 3 with 0 indicating the absence and 3 indicating the presence of an element. The maximum attainable score for a hospital was 51 (i.e., the sum of scores for all 17 measures).

Presentation:  We divide the 12 hospitals into three groups; high scoring, moderate scoring, and low scoring, based upon their total RTE scores.  We compare high-scoring hospitals (i.e., those that are best prepared to engage in language services provision) with moderate- and low-scoring hospitals across all seven elements. In addition to identifying best practices employed by high-scoring institutions, we will discuss facilitators of and barriers to system change. We present specific recommendations for improving language services across the three groups based upon their level of engagement.

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What makes this evaluation unique is that it is based on the perspectives of multiple stakeholders, ranging from executive leaders to frontline clinical and administrative staff, across 12 hospitals.  With the information obtained we are able to describe the nature and extent of language services that are currently provided within each hospital as well as identify the systems-level facilitators and barriers to improving these services.  This presentation will: 

  • Highlight the strategies and practices of California public hospitals to improve language services;

  • Identify the system-level factors that facilitate the provision of high-quality language services.

  • Offers lessons and best practices to hospitals to meet their specific needs;

  • Illustrates ways in which to engage public hospitals in undertaking system-level change; and
  • Introduce an innovative self-assessment tool (the RTE instrument) that hospitals can use to gauge their readiness to engage in providing high-quality language services for LEP populations.  It is our hope that the RTE instrument will become a useful self-assessment tool for all hospitals to employ in the future.

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Some of the strategies that participating hospitals used to improve language access included:

  • Establishing a centralized program or department dedicated to coordinating language services, which enables the hospital to provide services more efficiently as well as to oversee the quality of services being provided.
  • Making the commitment of hospital CEOs and other leaders to improving language access highly visible to staff members, so that an organizational culture is created and sustained in which language services are perceived as essential to providing safe, high-quality care rather than as a barrier to productivity.
  • Raising staff members’ awareness and understanding of the importance of providing language services to LEP patients by framing it within the context of patient safety and quality improvement, two top priorities for all hospitals.  This awareness is sustained through frequent dialogue between hospital leaders and staff members as well as though ongoing staff training and education.
  • RTE Summary Tool.pdf (85.6 kB)
  • Presentation Information:

    Program: Peer-to-Peer Practice Advancement Sessions
    Primary Category: Language Access
    Subtopics: Interpreter services—development and management, Interpreter practice—skills, day-to-day issues, Interpreter training, assessment and certification, Remote/telephonic interpreting, Bilingual staff, Translation, Organizational plans, policies, management strategies, Quality improvement, Qualitative research design, Program/intervention evaluations

    Region Addressed by Presentation: US - California
    Organization: Hospital
    Population/Demographic: Limited English Proficient patients
    Keywords: system-level change, organizational innovation, multi-site evaluation

    Juliet Yonek, MPH , Health Research and Educational Trust (affiliate of the Amercian Hospital Association), Chicago, IL
      Director, Program Evaluation
      Health Research and Educational Trust (affiliate of the Amercian Hospital Association)
      One North Franklin St, 30th floor
      Chicago IL, USA 60606

      Phone: 312-422-2644
      Fax: 312-422-4568
      Email Address:

      Biographical Sketch:
      Juliet Yonek, M.P.H., is Director, Program Evaluation for the Health Research and Educational Trust (HRET), an affiliate of the American Hospital Association (AHA). She is the project director for a multi-site evaluation of language services provision in California public hospitals, funded by the California-Endowment. She served as the lead analyst for a nationwide survey of hospital language services conducted in 2005 and was a co-author of the report that resulted from this study. Ms. Yonek worked with the Department of Health and Human Services, Office of Civil Rights on an initiative focused on effective communication in hospitals, and with the American Medical Association’s Institute for Ethnics on a project related to Patient-Centered Communication for vulnerable populations. Ms. Yonek holds an M.P.H. in Epidemiology and Biostatistics from San Diego State University and a B.S. in Animal Physiology and Neuroscience from University of California at San Diego.