ED Accreditation Update
Joint Commission proposed requirements on culture, communication out for field review
Patient-centered care also included in Joint Commission proposals
After months of anticipation, The Joint Commission has released its "proposed requirements to advance effective communication, cultural competence, and patient-centered care" for field review. If approved, they will represent some significant new challenges for ED managers.
Keys areas likely to affect the ED include:
- identifying the method the patient would prefer to use to communicate;
- making sure the patient is aware of his or her right to have an interpreter provided free of charge;
- documenting the fact that a language or communication need exists;
- using tools such as teach-back or read-back during patient education;
- accommodating cultural differences, in comparison with the current standard that says "respecting"
- ongoing staff training about cultural differences and their role in patient care. (Editor's note: Go to www.JointCommission.org/Standards/FieldReviews/field_ecccpc to review all of the proposals.)
The Joint Commission is taking steps to ease the transition to these new requirements, notes Amy Wilson-Stronks, MPP, project director for health disparities in the Division of Standards and Survey Methods. "Part of our work has involved developing an implementation guide, which will come out at the same time the standards are finalized in January 2010," she shares. "It will give some specific examples of resources and tools that can be used to meet the requirements." The earliest date that new requirements would be expected to be implemented is January 2011.
Challenges to the ED
When developing these proposed requirements, a 25-member panel of experts followed the care processes for hypothetical patients. "That really allowed us to understand how these issues can impact care, but for the ED there are lots of specific challenges because the work there is very quick and very acute, and the only thing we can add is that we certainly try to be sensitive to the fact that these standards mean different things to different departments," says Wilson-Stronks. "The leadership needs to provide their department with the resources and tools they require."
Staff education might be one of the most challenging of the requirements, but India Owens, MSN, CEN, director of emergency services at Clarian West Medical Center in Indianapolis, says there are keys to meeting that challenge. "You have to make the education relevant to your department and the patient demographics," she advises. "If the staff does not understand why these things are being required, they won't absorb the information."
Get to know your 'target'
Owens says the release of the proposals "prompted me to look at the demographics here." She notes that her catchment area includes more than just her hospital's home county, which increases patient diversity. "You have to know the target," Owens explains. "Part of the challenge involves understanding which groups are represented, so I know how to train my staff."
All patients are registered electronically, she says. "Out computer gurus can capture religion and ethnicity, so I can write a report that tells me the top three religious preferences, the top three ethnicities, and so forth," says Owens. Since this is aggregate information, she adds, there is not a privacy issue involved. "All I want to know is what my top three groups are that I need to educate my staff about," she says.
Since the standard is new, she continues, "I have not taken the step to determine this information relative to creating an educational plan. However, I ran it just for fun and found that our top three ethnicities are Caucasian, African-American, and Hispanic."
Owens says most of her education is done online, including post-competency exams, "So, the staff can do it at their leisure, day or night."
What does TJC want from ED managers? While The Joint Commission generally seeks to avoid proscriptive language in its standards, it still has a number of expectations for ED managers and other health care leaders when it comes to its "proposed requirements to advance effective communication, cultural competence, and patient-centered care," says Amy Wilson-Stronks, MPP, project director of health disparities in the Division of Standards and Survey Methods. For example, Wilson-Stronks notes, when it comes to effective communication, "The point we are trying to emphasize is that patients present with various communication needs that should be considered." These needs, she points out, might not only include language interpreters; they might include devices such as hearing aids. "If you're serving a large population of non-English-speaking patients, you should make sure your triage and floor nurses and doctors are aware of how to access language services," Wilson-Stronks adds. Patients also must be made aware of those services. Placing "I speak [insert language]" cards at the triage desk is one effective strategy, says Wilson-Stronks. "The other piece ED managers might want to think about is making sure the staff is aware of how to determine the need for an interpreter," she adds. Make sure your staff is trained on accessing interpreter services when a patient is limited English proficient and identifies another spoken language. It also is important that ED staff are trained on how to use the services. A patient advocate India Owens, MSN, CEN, director of emergency services at Clarian West Medical Center in Indianapolis, goes a step farther in her department. "We have bilingual staff that can register patients and record their chief complaint, but our goal is always to get a medical-grade interpreter who is the patient's advocate and not the hospital's advocate," she says. "You can't expect the provider to present care options; you need that advocate." Interpreters can be found through the International Medical Interpreters Association (www.imiaweb.org/default.asp). "Some interpreters contract individually, but most work through some sort of collaborative to enhance availability," Owens explains. According to the Bureau of Labor Statistics (BLS), medical interpreters' salaries can range from a low of under $9.88 hourly to a high of $30.91 hourly, "which equates to just over $60,000 for someone working full-time," she says. The average salary is $17.10 hourly, which is a bit more than $34,000 annually. These data, she adds, are based on BLS information for 2006, which is the most recent information readily available. As far as documenting the need for communication assistance, says Wilson-Stronks, that can take place during admission or assessment. What is new about the documenting proposal is that documentation would be expected to be used for planning purposes by gathering aggregate data, she says. An interesting new distinction involves patients' cultural and personal beliefs and religious and spiritual practices. Formerly, notes Wilson-Stronks, providers were required to "respect" those differences; now they must "accommodate" them. "This can involve issues like death and dying, or certain rituals," she explains. "You look for a point of reasonableness, but there are ways of making accommodations for these beliefs even when on the face of it they may appear to be unusual." One example Wilson-Stronks cites involved the preference of the Gypsy population to have a light put underneath the bed, usually a burning candle. "Obviously, you do not want to have a candle burning under a hospital bed," Wilson-Stronks observes. "One hospital has used a flashlight, which appeased the patient and the family, but did not cause a safety issue." Because the new requirements address patient-centered care, the 25-member expert panel that developed them explored a broad range of issues. "One thing that surprised us was when patients go to the hospital and have mobility issues — for example, they are very large, and unable to get up and access the exam table — there aren't always ways to accommodate them," notes Wilson-Stronks. "Or, they may walk with the assistance of a cane, but when they were moved from the ED to radiology, the cane does not follow them." This inability to accommodate patients also could impact the assessment process (if the patient has trouble walking), she adds. Finally, says Wilson-Stronks, the education requirement has been broadened to include patients and staff. "The Joint Commission has proposed making the staff education requirement dealing with orientation related to cultural sensitivity more specific to include sensitivity on the cultures of patients and staff," Wilson-Stronks explains. "Training that helps employees better understand different beliefs and perspectives and promotes behavior that is respectful and nonjudgmental is important for both relationships between staff and patients and among staff." |
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