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New Standards Address Patient-centered Communications
ED setting presents special challenges
In July 2011, Joint Commission (JC) surveyors will begin holding hospitals accountable for some of the elements of performance (EP) contained in new patient-centered communication standards that were first unveiled last summer. The new accreditation standards, which are currently in the pilot phase of implementation, are designed to ensure that hospitals take all necessary steps to make sure that patients get the information and support necessary to make appropriate decisions about their own care.
While the JC has had standards for patient-centered communications for years, Christina Cordero, PhD, MPH, associate project director, department of standards and survey methods, division of healthcare quality evaluation, the Joint Commission, explains that years of involvement with an initiative focused on hospital language and culture led the JC to conclude that new standards were needed. "One of the interesting things we found was that most of the organizations we worked with as part of that initiative had some type of language interpreting services," she says. "But when we interviewed the front-line staff, we found that many of the staff weren't using the services that were provided, for several reasons."
For example, many staff members would complain that the telephone interpreting services their hospitals offered tended to be cumbersome or difficult to use; in other cases, passwords would be required to use these services, but staff didn't have ready access to these passwords, says Cordero. "Many times, we also found that the telephones were locked in drawers or closets, and people didn't have keys in order to access these tools to their full potential," she adds. (Also, see "Use appropriate tools, strategies to overcome challenges of communicating in an emergency setting," below.)
Problems like these prompted the JC to develop new accreditation standards and to develop a guidance monograph to help hospitals most effectively meet these standards. That document, Advancing Effective Communication, Cultural Competence, and Patient and Family-centered Care: A Roadmap for Hospitals, is available for download at www.jointcommission.org/Advancing_Effective_Communication.
Alleviate stress and fear
The first of these new accreditation standards to be fully implemented are EP 29, which states that hospitals are to prohibit discrimination "based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression," and EP 28, which states that the hospital will "allow a family member, friend, or other individual to be present with the patient for emotional support during the course of stay."
Hospitals will be held accountable to these accreditation standards beginning in July 2011, says Cordero. "The intent behind [EP 28] is to just make sure patients can identify an individual who they want to be with them in the hospital, and that the hospital will allow this person to be there. The policy is not intended to dictate visitation policies or to call for open visitation," she stresses. "It is really about alleviating fear and stress for patients when they are alone in the hospital. There was a lot concern that the presence of individuals would put stress on the patient, when the reality is that the opposite is true. It really does help patients feel better about being in the hospital."
For compliance with EP 28 and EP 29, JC surveyors may review a hospital's written policies, mission statement, staff training procedures, and they may gauge staff awareness and understanding of these standards, says Cordero. "We also put a note with this element of performance that the hospital would allow the presence of this individual, unless it infringed on the rights or safety of other patients or it is contraindicated by treatment, so there is some flexibility to determine whether or not it is appropriate to allow the presence of some people," adds Cordero.
Determine patient needs
Hospitals will have at least until January 2012 before JC surveyors will include two other new patient-centered communications standards in their hospital reviews. The first of these, EP 1, directs hospitals to identify a "patient's oral and written communication needs, including the patient's preferred language for discussing health care." The second provision, EP 2, directs hospitals to then communicate with patients "in a manner that meets the patient's oral and written needs."
To be in compliance with these provisions, hospitals need to try to determine what written materials patients understand, or if they have health literacy needs, and what kind of materials they need, explains Cordero. "In addition, communications needs can be personal devices that people have brought with them to the hospital such as eyeglasses or hearing aids," she says. "Sometimes throughout the care continuum, people are separated from those devices, so it is a matter of bringing patients back their glasses or hearing aids to facilitate communication between patients and providers."
Surveyors are likely to review what policies and procedures are in place to insure patient communications are effective; they may also conduct patient interviews, review staff training procedures, look at what resources are in place to help with communications, and find out how these resources can be accessed, explains Cordero.
Use appropriate tools, strategies to overcome challenges of communicating in an emergency setting
Most would agree that the concept of patient-centered communications makes sense and is a worthy goal, but getting there can be especially challenging in the ED, where decisions often must be made quickly and families are frequently under great stress. "A fair number of people come into the ED not able to communicate in the way they normally would. They may be unconscious, they may be in extreme pain, they may be very frightened," explains Matthew Wynia, MD, MPH, director of the Institute for Ethics at the American Medical Association in Chicago, IL, and a member of the expert advisory panel on which the Joint Commission relied in establishing its accreditation standards for patient-centered communications. "These things are true in any health care encounter, but they are much more exaggerated, much more common, and much more severe in the ED."
Consider, for example, the case of someone who speaks English as a second language, and is quite fluent, until he becomes very sick, and then all of the English suddenly becomes inaccessible, says Wynia. "That kind of thing happens in EDs even more than it does in the inpatient, hospitalized setting," he says. "When people are really scared, they don't process information normally."
In these cases, it can be helpful to use the "teach-back" method, where you ask patients to repeat instructions or information you have provided to them. "Also, when you hear something from the patient, you should summarize what you heard and repeat it back to the patient," says Wynia. "I think it is the only way to know for sure that you and the patient are on the same page."
Wynia acknowledges that in a stressful situation, it is harder for patients to learn and absorb information, so they may not repeat back information correctly the first or second time. "That may require bringing in a support person, family member, or community resource for further education," he says. "The patient may also need a follow-up appointment that is a little sooner than otherwise."
Have competent interpreters on hand
In cases where there is an obvious language barrier, then EDs have a particular obligation to make sure they have resources in place to communicate, stresses Wynia. "This could be a telephone or an in-person interpreter, but it really should be someone who is competent and qualified to do interpretation," he says.
However, Wynia emphasizes that providers should never rely on a patient's child for interpretation. "You just don't get a quality interpretation of the material because the child is unlikely to know the types of terminology you are using," he says. "Children are also especially unlikely to ask their parents the kinds of questions you might need to ask personal, probing questions that put the child in an uncomfortable position."
Language isn't the only barrier to communication that can occur in the ED. You could be treating a patient who is deaf, or someone who needs to be intubated. "In these types of cases, you need to have a language board on hand so that patients can at least write things to you," says Wynia. "And these tools need to be readily available in the ED as opposed to a less acute setting, where you might have more time to pull resources together. In the ED, you might not have that kind of time."
Find weak links
One way to find weak links in your communications pathways is to complete an organizational assessment across the entire hospital, says Wynia, noting that it is the first step toward creating an environment where good communication can take place. "It is pretty common for there to be big differences from one part of an organization to another, so when comparing the ED to an inpatient oncology service, for example, you can see big contrasts," he says.
For the ED part of this process, Wynia recommends a complete, across-the-board assessment of communications with regard to:
As with other aspects of health care, improvement needs to be driven by data, stresses Wynia. "The only way to do that is to do a formal assessment so that you've got some data as to where you are right now. Then you can reassess in a year and see where you are after your interventions," he says.
Editor's note: To help with an organizational assessment, ED managers can find a "Communications Climate Assessment Toolkit" and a range of other surveys and instruments at www.ethicalforce.org, which is sponsored by the American Medical Association.