Understanding CLAS Standards

Understanding CLAS Standards Kaiser Permanente has adopted all fourteen Culturally and Linguistically Appropriate Services (CLAS) Standards which are aligned with and facilitate achievement of the; 1) Kaiser Permanente Promise, 2) Kaiser Permanente Mission, and 3) National Diversity Agenda Objectives. Annual CLAS Standards Training emphasizes access to Language Access Services provided at Kaiser Permanente San Francisco for our Limited English Proficient (LEP) and Hard of Hearing Members. 1. Definition: CLAS Standards - Culturally and Linguistically Appropriate Services (CLAS) Standards 2. What are CLAS Standards? CLAS Standards are federal guidelines and mandates developed by the Office of Minority Health (OMH) to improve access to health care for Limited-English proficient (LEP) individuals through the elimination of language and cultural barriers. 3. Which CLAS Standards are mandated? CLAS Standards 4 7 refer to Language Access Services; these standards are federally mandated for health care organizations that are recipients of federal funds. 4. Which CLAS Standards are mandated by Kaiser Permanente While Kaiser Permanente has adopted all 14 CLAS Standards CLAS Standards 4 7 are medical center wide policies (mandates) by providing Language Assistance Services. 5. CLAS Standards refer to which following topic areas? A. CLAS STANDARD 4 - Limited English Proficient and People with Hearing Loss B. CLAS STANDARD 5 - Language Assistance Service Rights C. CLAS STANDARD 6 - Competence of Language Services D. CLAS STANDARD 7 Signage and patient-related materials are available for Limited English Proficient (LEP) Members and People with Hearing Loss 6. Why does Kaiser Permanente conduct CLAS Standards Training? Kaiser Permanente conducts CLAS Standards training at each of its medical facilities in order to meet annual compliance standards. Annual CLAS Standards training enables LEP and Hard of Hearing members to receive equal access to care and service delivery through the use of interpreter services, language assistance, and cultural services. 2

Contents: 1. Understanding CLAS Standards. 2 2. Explanation of CLAS Review Guide and Procedure..... 4 3. National CLAS Standards Overview and Background.... 5 4. What are CLAS Standards.... 6 5. What Language Assistance Services does KPSF provide...... 7 6. How does a KPSF employee schedule an interpreter.... 8 7. Key differences - QBS L 1, QBS L 2, and Trained Interpreters... 9 8. Frequently Asked Questions...... 10 9. KPSF Facility Information Related to CLAS.. 11 10. Language Preference Reports for KPSF Members....... 12 11. Understanding the Importance of Health Literacy. 12 12. Federal Cultural and Linguistic Governing Laws...... 13 13. State Cultural and Linguistic Governing Laws.... 14 14. Response to Regulatory Mandates & Clinical Consequences of Miscommunication 15 15. Communication Challenges in the Clinical Encounter & Health Literacy.. 16 16. The Fourteen CLAS Standards.. 17 17. CLAS Standards Acknowledgment Form...... 19 18. CLAS Standards Review Form.... 20 19. CLAS Standards Review Answers Sheet... 23 20. CLAS Feedback Form... 26 Purpose: The purpose of the enclosed information is to review Culturally and Linguistically Appropriate Services (CLAS) Standards and guidelines associated with accessing interpreter services at Kaiser Permanente San Francisco Objectives: To gain an overall understanding of the CLAS Standards To understand what language assistance services are provided by KPSF To understand the difference among QBS L 1, QBS L 2, and Certified Interpreters To review frequently asked questions regarding the use of interpreters To complete a CLAS Standards Review Form To provide feedback for additional CLAS training 3

Explanation of CLAS Review Guide and Procedure The CLAS Review Guide contains information related to federal mandates for language access services for our Limited English Proficient (LEP) members. The CLAS Review Packet contains background information regarding CLAS standards, language assistance services provided at KPSF, differences among QBS L1, QBS L 2, and certified interpreters, frequently asked questions, a CLAS Standards Acknowledgement Form, a CLAS Standards Review Form, an answer sheet, and a feedback form. Please have those in your department review the CLAS information material, be prepared to answer the CLAS Standards Review Form, and sign off on the CLAS Standards Acknowledgment Form during CLAS Review Sessions. The CLAS Review Sessions are an opportunity for our staff to receive educational information and review our CLAS Standards for KPSF. During the review session staff will have an opportunity to review the CLAS material, complete the CLAS Standards Review Form, and complete the CLAS Standards Acknowledgement Form. This will also be an opportunity for staff to ask questions regarding CLAS and to clarify questions they might have regarding the CLAS standards. You have also been provided with an answer sheet for the CLAS Standards Review Form, which shows the correct answer and page number(s) where the correct CLAS information can be found. Procedure: 1. Please share the CLAS Review Guide with Staff. 2. Have them review the CLAS Material. 3. Attend the CLAS Review Session (View Display Tables) or review the CLAS Material. 4. The CLAS Display Tables contains similar information given in your review packet. 5. While viewing the CLAS Display Tables or reviewing the CLAS Material staff will complete the CLAS Standards Review Form. 6. Once the CLAS Standards Review Form is completed staff will also; A) complete, B) sign, and C) turn in the CLAS Standards Acknowledgment Form. 7. The CLAS Acknowledgement Forms will be submitted to Human Resources for documentation in order to meet annual compliance standards. 4

National Standards for Culturally and Linguistically Appropriate Services (CLAS) Standards In December 2000, the Office of Minority Health (OMH), U.S. Department of Health and Human Services, issued the final recommendations on national standards for Culturally and Linguistically Appropriate Services (CLAS) Standards in health care. It serves as a blueprint for federal and state health agencies, policy makers, and national organizations to follow for building culturally competent health care organizations and workers. The 14 standards are based on an analytical review of key laws, regulations, contacts, and standards currently in use by federal and state agencies and other national organizations. The standards were developed with input from a national project advisory committee composed of individuals representing State and Federal agencies, health care organizations and professionals, consumers, unions, and health care accrediting agencies. OMH conducted a four-month public comment period and held three regional meetings in early 2000 to solicit testimony and advice for the first draft of standards. The standards are intended to correct existing inequities in the delivery of health services and to increase the responsiveness of services to meet the individual needs of patients and consumers. The standards are inclusive of all cultures; however they are especially designed to address the needs of racial, ethnic, and linguistic population groups that experience unequal access to health care services. Ultimately, the aim of the standards is to contribute to the elimination of racial and ethnic health disparities and to improve the health of all Americans. The CLAS Standards are organized by theme: 1. Culturally Competent Care (Standards 1 3) 2. Language Access Services (Standards 4-7) are federally mandated 3. Organizational Supports for Cultural Competence (Standards 8 14) Under the CLAS Standards, health care organizations are encouraged to ensure that patients receive understandable and respectful care that is compatible with their cultural beliefs, practices, and preferred language. Kaiser Permanente Kaiser Permanente has adopted and supports the implementation of the fourteen CLAS Standards. The CLAS Standards provide a comprehensive, regulatory framework through which we assess, develop, and refine critical components of care delivery and access required to address the changing service needs of our members. In this regard, the CLAS Standards are aligned with and facilitate achievement of the KP Promise, Kaiser Permanente Mission, and the National Diversity Agenda objectives. The CLAS Review Sessions are an opportunity for staff to receive educational information and annually review CLAS Standards for KPSF. CLAS Standards training enables LEP and Hard of Hearing members to receive access to care and service delivery though use of interpreter services, language assistance, and cultural services. 5

What are CLAS Standards? 1. CLAS Stands for Culturally and Linguistically Appropriate Services. 2. CLAS standards are federal guidelines and mandates developed by the Office of Minority Health (OMH), which is part of the U.S. Department of Health and Human Services to improve access to health care for Limited-English proficient (LEP) individuals through the elimination of language and cultural barriers. 3. There are 14 standards, organized by themes. 4. Standards 1 3 refer to Culturally Competent Care 5. Standards 4 7 refer to Language Access Services; these standards are federally mandated for health care organizations that are recipients of federal funds. Failure to comply may result in loss of federal funds. 6. Standard 8 14 refer to Organizational Supports for Cultural Competence Kaiser Permanente has adopted all 14 Culturally and Linguistically Appropriate Services (CLAS) Standards. Kaiser Permanente has mandated Standards 4-7 as medical center wide policies by providing Language Access Services for LEP and Hard of Hearing Members. CLAS STANDARD 4 (Limited English Proficient and Hard of Hearing Members) Offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each member with limited English proficiency at all points of contact, in a timely manner, during all hours of operation. CLAS STANDARD 5 (Language Assistance Service Rights) Provide to members in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. CLAS STANDARD 6 (Competence of Language Services) Assure the competence of language assistance provided to limited English proficient members by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services except on request by the member. CLAS STANDARD 7 (Signage in Service Areas for the Limited English Proficient (LEP) and Hard of Hearing Members) Make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups in the service area. 6

What Language Assistance Services does Kaiser Permanente San Francisco provide? Language Preference Field (LPF) enable KP to plan for our members needs; Spoken Language Field helps us plan for language service needs, Interpreter Required Field helps us determine the need for interpreters, Written Language Field allows us to send in-language material to our members. On-site Interpretation Services (OSI) KP provides on-site interpretation service to members for inpatient, outpatient, emergency care and other services at Kaiser Permanente San Francisco at no cost to members or their families. We provide service for ALL LANGUAGES (including ASL) either by staff interpreters, language line, or by using an outside vendor. Language Line Services in case on-site interpreters are not available, providers are encouraged to use Language Line. Information cards are available for quick reference. Chinese Interpreter Call Center (CIC) provides telephone interpretation for Chinese-speaking members in the Northern California Region to access services of the Regional Appointment and Advice Call Centers and all departments in the San Francisco Medical Center. Translation Services KP has in-house professional translators and reviewers who can translate a document from English into another language and vice-versa. To ensure accuracy and quality, every project goes through a formal process of translation and review. Qualified Bilingual Staff (QBS) Program The Labor Management Partnership (LMP) Bilingual Program was established as a Kaiser Permanente (KP) Northern California Regional Initiative. It was developed to build capacity and improve the quality of the existing and future workforce to best meet the language needs of our Limited English Proficient (LEP) patients/members. 1) QBS Level 1 A Kaiser Permanente employee of one of the partner unions whose language skills have been assessed and can provide basic language assistance to our members where a basic understanding of medical terminology is not required. Examples of assistance include making medical appointments and providing directional assistance to members. They do not interpret in the clinical setting. 2) QBS Level 2 A Kaiser Permanente employee of one of the partner unions whose language skills have been assessed and can provide basic language assistance to our members in addition to providing higher language skills where medical terminology is required. 7

How does a KPSF employee schedule an interpreter for a Limited English Proficient (LEP) Member? There a several choices available to KPSF employees when assisting LEP members. Remember, we provide service for ALL LANGUAGES (including American Sign Language) either by staff and on-call interpreters or by using an outside vendor. Contact Information as follows: 1. Advance or Future Requests: Email to SFO LCS 2. Office Hours for Linguistic & Cultural Services Office Hours: 8:00 am to 12:30 pm & 1:00 pm to 4:30 pm (Monday Friday) 3. Service Hours Cantonese/Mandarin 7:00 am to 8:00 pm Monday, Tuesday, Wednesday and Friday 7:00 am to 5:00 pm Thursdays Spanish 7:00 am to 6:30 pm Monday Thursday, 7:00 am to 5:00 pm Friday Vietnamese 8:30 am to 5:00 pm Monday, Wednesday, and Fridays Arabic, Korean, Russian and Tagalog available upon requests On-site services in other languages may be available if requested in advance. Language Line Services are available 24 hours a day, 7 days a week and can be used when on-site interpreters are unavailable. American Sign Language - Services are available 24 hours a day, 7 days a week available upon requests 4. Urgent or Same Day Service For same day requests: Call 3-2721 and follow the prompts 5. Language Line In case on-site interpreters are not available ACCESS: 1-800-523-1786 Client ID: 201423 Language Needed: Personal Code: Cost center number for your department THERE ARE NO COSTS TO INDIVIDUAL DEPARTMENTS OR COST CENTERS TO UTILIZE LANGUAGE LINE SERVICES. 6. Translation Services ACCESS: Call 3-2721 and follow the prompts for translation requests or e-mail to SFO LCS Translation-Services 8

Understanding key differences among QBS L1, QBS L2 and a trained health care interpreter? Currently, there are 5 QBS languages : Cantonese, Mandarin, Spanish, Vietnamese, and American Sign Language (ASL). QBS L1 A Kaiser Permanente employee of one of the partner unions whose language skills have been assessed and can provide basic language assistance to our members where a basic understanding of medical terminology is not required. They do not interpret in the clinical setting. Situations when QBS L1 should utilize their language assistance skills: 1. Scheduling appointments 2. Taking simple/non-complex complaints or patient/member grievances 3. Providing location-based directions 4. Providing non-medical instructions 5. Performing sight translation limited to customer service needs (directions, marketing brochures, appointment cards) QBS Level 2 A Kaiser Permanente employee of one of the partner unions whose language skills have been assessed and can provide basic language assistance to our members in addition to providing higher language skills where medical terminology is required. Trained Interpreters Are interpreters who are able to interpret complex instructions and directions, including medical terminology. Interpreting is their primary job. Kaiser Permanente s staff interpreters must be certified through a program such as the Health Care Interpreter Certificate Program of City College of San Francisco or have successfully completed a certification program within their 1 st year of employment. In addition to utilizing their language skills QBS L1, QBS 2, and Trained Interpreters utilize their cultural knowledge, skills, and backgrounds to serve as cultural ambassadors in the clinical setting. 9

FREQUENTLY ASKED QUESTIONS: Can I ask a member to bring an interpreter? No. A member needing interpreter services will be informed of Kaiser Permanente s language assistance services at no cost to the member when an appointment is scheduled. Can a minor interpret for a patient/member? No. Minors should only be used in an EMERGENCY SITUATION when a QUALIFIED INTERPRETER is not available. As a member, do I need to be worried about accuracy during an interpreting encounter? No. In every interpreting encounter KPSF must ensure that the interpretation is neutral, impartial, and of the highest quality. As a KP provider or employee, do I need to document when an interpreter is provided during a medical visit? Yes. All outpatient interpreter encounters must be documented in the Interpreter Services Questionnaire (ISQ). All inpatient language assistance and interpreter encounters are captured in the designated flow sheets or documented in the electronic medical record and must include the date, time, name, NUID of staff interpreter or the phone number of the interpreter. If a member declines an interpreter it must also be documented. Information related to members needs for language assistance is available in HealthConnect. How do people with hearing loss or LEP Members get informed of their rights to an interpreter? Signage is posted at key points of contact: in hospital entrances, emergency departments, waiting rooms, etc. Members may also be informed of their rights by staff. What should the Language Assistance Service Rights signage say? The signage should advise members on how to access interpreter services 24 hours a day, at no cost to the member. In addition, members will be informed on how to address/file a complaint regarding interpreter services. What is my role, as a staff/clinician, to inform a member of their rights to language services? ALL STAFF WILL BE REQUIRED TO ASSIST MEMBERS ON HOW TO ACCESS INTERPRETERS AND HOW TO ADDRESS/FILE COMPLAINTS ABOUT INTERPRETER SERVICES When and where are we required to provide language assistance services to our LEP Members We are required to ask our LEP Members if they want language assistance at every point of contact and provide the appropriate language assistance services to the LEP member every time it is requested. What type of information needs to be translated for LEP members? Vital documents (such as those documents critical to patient care i.e. patient instructions, consent forms, and medical information), signage and way finding maps as well as frequently used patient care materials will be translated into the threshold languages of LEP groups where threshold languages are required. The threshold languages for the San Francisco Medical Center are currently Chinese and Spanish. Can I assume that Hard of Hearing and Limited English Proficient (LEP) members are aware of their rights to an interpreter? No. Do not assume that Hard of Hearing and LEP members are aware of their rights to an interpreter. Information e.g. Interpreter Services pamphlets, concerning member s rights is available through Member Services and posted at key points of contact in the medical center. 10

KPSF Facility Information Related to CLAS Speaker Phones Available in Patient Rooms: In 2005 all phones in the patient rooms were converted to speaker phones to enhance the opportunity to utilize Language Line Services any time of the day. Medical center staff may utilize Language Line Services when staff interpreters or QBS Staff are not available in person or onsite. Services to Our Members: Remember that language assistance must always be offered to LEP members and minor children should never be used as interpreters. Always document a member s electronic medical record: If a member declines language assistance and uses their own English skills, uses an adult family member or friend to interpret Anytime an interpreter is used during the encounter Anytime the information in a document is orally transmitted to the member in his/her preferred language. Patient Communication Aid: The Patient Communication Aid is a trilingual document that can be used in the hospital setting. The Patient Communication Aid provides valuable information to members regarding patient information, access to objects in the hospital room, and communication. The Patient Communication Aid is available in English, Spanish, and Chinese in San Francisco. Using Language Assistance Services in California: The web-based training course named Using Language Assistance Services in California can be viewed on the KP Learn Website. This training course covers why, when, and how to use Kaiser Permanente language assistance services for members. Senate Bill 853 Requirements Passed in 2003, Senate Bill 853, which is a state law, required the Department of Managed Health Care to develop a set of regulations to address the needs of Limited English Proficient (LEP) Health Plan enrollees 11

LANGUAGE PREFERENCE REPORTS FOR KPSF MEMBERS April 2009 Language Preference Spoken Written Preference for KPSF Members English 82.36% 83.29% Cantonese (Chinese Dialect) 8.10% ******* Spanish 6.13% 5.82% Mandarin (Chinese Dialect) 1.03% ******** Other Languages 1.02%.65% Tagalog.44%.33% Vietnamese.41%.35% Russian.22%.19% Korean.15%.14% Japanese.14%.11% Chinese ****** 9.12% Total 100% 100% Understanding the Importance of Health Literacy 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 (Health People, 2010). Health Literacy is fundamental to quality care and service! 1) Nothing -- not age, income, employment status, educational level nor racial/ethnic group -- affects health status more than literacy skills. 2) Clear communication between patients and health care providers is crucial. 3) Good communication equals healthy patients. 12

Legal/Regulatory Requirements and Accreditation Federal Cultural and Linguistic Governing Laws KP is required to provide culturally and linguistically competent care under numerous statutory, regulatory, contract and accreditation authorities. Below are some examples: Federal Laws, Policies & Enforcement Presidential Executive Order 13166 Enforcing Agency All partnering regulatory & accrediting bodies Topics Referenced Improving Access to Services for Persons with Limited English Proficiency (LEP) Americans with Disabilities Act (ADA) Department of Health & Human Services (DHHS), Office of Civil Rights To provide a clear & comprehensive national mandate for the elimination of discrimination against individuals with disabilities Culturally & Linguistically Appropriate Services (CLAS) The Emergency Medical Treatment & Active Labor Act (EMTALA) DHS, CMS Dept of Minority, & Health Joint Commission on Accreditation of Healthcare Organization (JCAHO) s & DHS Culturally competent care Language access services Organizational support for cultural competence US federal law governing assessment & transfer of patients seeking emergency care For further information on these regulations/requirements, contact your local accreditation, regulatory, licensing, compliance liaisons. 23 13

State Cultural & Linguistic Governing Laws State Cultural & Linguistic Governing Laws California Laws & Policies Senate Bill SB853 DHS, Medical Managed Care Department Policy Letters Enforcing Agency Department of Managed Health Care (DMHC) DHS* Topics Referenced Set of regulations that require Healthcare Organizations to develop a comprehensive program to improve access to health care services for LEP (Limited English Proficient) enrollees Clarification regarding Medical managed care plans & contract requirements to providing cultural & linguistic services California Code of Regulations Sections (Title 22) DHS Guidelines for two plan Medi-Cal models to provide cultural & linguistics services on a two plan model Medi-Cal Service Contracts Health & Safety Code: 1259 & 1300.67 Healthy Families Contract Other State Programs Contracts [Access for Infants & Mothers (AIM), Major Risk Medical Insurance Program, etc. (MRMIP)] DHS JCAHO, DHS, CMS MRMIB MRMIB Requirements for services provided to populations covered under Medi- Cal Requirements to provide access to information regarding basic health care services & to ensure adequate & speedy communication between patients & staff Contractual requirements for services provided to populations covered under Healthy Families Contractual requirements for services provided to populations covered under other state regulations 24 14

Response to Regulatory Mandates Language Assistance Policies & Procedures Overview In response to regulatory mandates and as the U.S. population becomes more diverse, Kaiser Permanente developed the following policies and procedures to serve the cultural and linguistic needs of our members: Language Assistance Service Rights Interpreter Services Translation Services Right to file grievance/complaint related to interpreter services Competence of Language Services Necessary Signage in Service Areas 25 Clinical Consequences of Miscommunication Breakdown In Communication: What Are The Flags & Consequences? Language barriers Breakdown Communication mismatch between what the patient/member is saying verbally and non-verbally Consequence Awkwardness during the visit/encounter Resistance or lack of adherence to care plan Retreat into silence and/or cover up/lie Dissatisfaction with care and/or does not return for care Misdiagnosis or complication with medical treatment Lower MPS Scores 15

Communication Challenges in the Clinical Encounter Research Tells Us That 35% 30% 25% 20% 15% Different Ethnic Groups Face Greater Difficulty in Communicating with Physicians 33% 27% 23% 19% 16% 10% 5% 0% Total Hispanic Asian American African Am erican White Base: Adults with a health care visit within a two year period (2000-2001) Communication problems include understanding doctor, feeling doctor listened, had questions but did not ask. Source: The Commonwealth Fund 2001 Health Care Quality Survey. http://www.cmwf.org/surveys/surveys_show.htm?doc_id=228171 16

The Fourteen Culturally and Linguistically Appropriate Services (CLAS) Standards in Health Care Culturally Competent Care 1. Health care organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. 2. Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. 3. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. Language Access Services (Standards 4-7 are federally mandated) 4. Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. 5. Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. 6. Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/ consumer). 7. Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. Organizational Supports for Cultural Competence 8. Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. 9. Health care organizations should conduct initial and ongoing organizational self-assessments of CLASrelated activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. 10. Health care organizations should ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated. 17

11. Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. 12. Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS related activities. 13. Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. 14. Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information. 18