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December 16, 2011 

NYC Civil Rights Oversight Hearing: Cultural Competency Training at HHC


Good morning, my name is Caroline Jacobs and I am the Senior Vice President for Safety and Human Development at the New York City Health and Hospitals Corporation (HHC). I am pleased to have the opportunity to provide testimony on HHC’s programs and initiatives to provide culturally competent healthcare.

Each year, HHC provides care for approximately 1.3 million very diverse New Yorkers. While such diversity presents challenges to delivering care, HHC has made – and continues to make - investments in training and services and is an industry leader in providing culturally competent and linguistically appropriate services. We are committed to providing care to all of our patients that is safe, responsive, understandable and effective.

The provision of culturally competent care is required by current laws, regulations and accreditation agencies’ standards. At HHC, we ascribe to the belief that the provision of culturally competent care:

  • Is an essential component of HHC’s mission, vision and values;
  • Leads to improvements in quality and patient safety;
  • Is necessary to accommodate changing patient and neighborhood demographics;
  • Reduces health disparities; and most importantly,
  • Is the right thing to do.

HHC’s efforts to provide culturally competent health and behavioral health services are guided by:

  • An understanding of the important role of culture, race, class, age and gender in interpersonal and professional encounters, especially in health care delivery;
  • An understanding of the historical and socio-political factors that impact the health and mental health of minority populations, such as racism, immigration patterns and human rights’ violations.
  • The need to collaborate with ethnic and racial community-based organizations. For example, working with neighborhood organizations/groups, faith-based organizations, spiritual leaders, healers, and advocacy groups as well as the patient’s family and support network to ensure appropriate responses to individual health needs.

Culturally Competent Workforce
The underpinning of HHC’s organizational commitment must be an awareness of the needs of our patients and implementation of evidence-based interventions that effectively address identified needs. As you can imagine, this is an ongoing, dynamic process that requires periodic assessment of the cultural competency of our workforce, ongoing evaluation of the effectiveness of our diversity training programs, and formal and informal linkages with the communities that our facilities serve. As part of our ongoing efforts, I am happy to announce this morning that we will roll out a new cultural competency staff orientation curriculum in the middle of next year.

Even as we develop the new curriculum, every HHC employee currently receives cultural diversity training to improve his/her assessment, diagnostic, treatment and care management skills in order to more effectively work with patients from different cultures. Beyond the initial training that a new employee receives, ongoing training is periodically conducted by HHC’s facilities that include workshops for staff, Grand Rounds on cultural diversity for clinicians, and continuing education classes on cultural competency.

One example of our ongoing investment is the inclusion of a mandatory component to our staff training curriculum regarding awareness of the health needs of lesbian, gay, bisexual and transgender individuals to help to reduce health disparities related to sexual orientation and gender identification. HHC was the first public healthcare system in the nation to mandate this training.

Some HHC facilities have instituted additional training to focus on the LGBT community. For example, medical residents and other students at Coney Island Hospital receive training focused on the unique needs and concerns of LGBT adolescents. The objectives of their training include finding risk factors faced by LGBT youth, discussing how homophobia contributes to LGBT youth’s health outcomes, and identifying elements of competent LGBT healthcare delivery.

Our efforts to provide culturally competent care are not limited to training staff. They extend to the implementation of unique programs tailored to meet the needs of individual communities. Some examples of these initiatives include:

  • The Medina Health Center operated by Harlem Hospital Center, that provides core medical services to a burgeoning population of African immigrants and members of the Muslim community.
  • Coney Island Hospital operates a substance abuse program for Russian patients who are not proficient in English. These patients are treated by a team of clinicians who speak Russian, many of whom are immigrants themselves. These practitioners have a unique perspective on how best to address the needs of this community.
  • Woodhull Medical and Mental Health Center runs a program that focuses on depression suffered by their geriatric patient population. The demand for this service has been almost exclusively among Spanish-speaking patients. Woodhull has translated all of the program’s print materials into Spanish, and has staffed the service with both a Spanish-speaking psychiatrist and a Spanish speaking care manager.
  • Elmhurst Hospital Center operates psychiatric inpatient units that address the needs of both Spanish speaking patients and Asian patients who primarily speak Cantonese, Mandarin or Korean. Many of the staff on these units speak the languages of their patients.
  • Queens Hospital Center operates a Diabetes self-management education program that conducts monthly support groups in English, Spanish and French Creole. Offering these support groups in the preferred languages of the patient is essential in enabling patients to engage in self-management and experience improved outcomes.
  • Lincoln Hospital operates the Viva Mujer (Long Live Women), Viva Los Hombres (Long Live Men) & For You, For Life! Cancer Outreach Program that promote public education in the areas of cancer screening, prevention, and early detection. These programs are very important to the community because many South Bronx residents are immigrants. As newcomers to the country, immigrants are often intimidated by mainstream culture, language and beliefs, and they are not familiar with the health care system and the services available. Lincoln’s staff and volunteers help break some of these language and socio-cultural barriers, which at times become obstacles to obtaining much needed cancer screening. The program provides screening services for breast, cervical and prostate cancer.
  • Also at Lincoln, staff are focused on the unique needs of LGBT youth and deploy an interdisciplinary team approach in their Adolescent and Family Planning Clinic Sessions. Team members include physicians, nurses, health educators, psychologists, HIV counselors and health educators who, together, are able to accommodate the patients’ medical and psychosocial needs.
  • On Staten Island, HHC has partnered with many community-based organizations including Project Hospitality, El Centro del Inmigrante, Make the Road New York, the JCC, the African Refuge, Staten Island branch of the NAACP, Staten Island Liberian Community Association, Sierra Leone Association, the Ghanaian Society, Staten Island Family Health Care Coalition, and the Staten Island Clergy Leadership to seek their assistance in reaching into immigrant communities to help inform them about the primary care services that we provide in the borough. Additionally, we worked to ensure that bilingual clinicians and staff were available at our two neighborhood family health centers and at our mobile medical office sites. Spanish is the language most often spoken by our patients on Staten Island but staff are also proficient in other languages including French, Hindi, Haitian Creole, Russian, Tagalog and Urdu.

The 1.3 million patients who receive health care at HHC facilities belong to many different ethnic groups, speak a myriad of languages and come from the different cultures that comprise New York City. We recognize that being able to speak a patient’s language is very important in the care delivery process and later in this testimony I will discuss our language assistance services. But speaking someone’s language is just one aspect of cultural competence. Consider that of HHC’s patients: 43% are Hispanic, 35% are Black, 8% are Asian, 6% are White and the balance are from other racial backgrounds. The ethnic groups represented include African-Americans, West Indians (of French, Dutch or English cultural backgrounds), Hispanics from Puerto Rico, Central and South America and parts of the Caribbean, Asians (including India, Pakistan, China and Korea), Africans, and people from the Middle East and Europe.

In 2007, in order to assist HHC’s facilities with challenges inherent in meeting the LEP patient population’s language access needs, HHC created the Center for Culturally and Linguistically Appropriate Services (CLAS). The role of CLAS is to oversee the implementation of the HHC Language Access Plan by providing centralized support and resources for the provision of culturally and linguistically appropriate services throughout all HHC facilities. Some of the work that the CLAS office performs includes:

  • Overseeing cultural competence education and training, including: planning, developing and facilitating curriculum modules for cultural competence that reflect best practices and that meet the needs of HHC’s diverse patient populations.
  • Ensuring the implementation of the National Culturally and Linguistically Appropriate Service Standards across HHC and to providing guidance, education, and support to facility Language Access Coordinators to build a CLAS infrastructure that promotes patient safety and quality of care.
  • Overseeing interpreter quality, training and assessment and establishing curricula to meet quality standards for healthcare interpreters at HHC facilities.
  • Overseeing language access vendor bids/contracts, quality of services, complaint resolution and utilization.
  • Optimizing access to translated patient education materials and documents to HHC staff.
  • Maximizing efficiency and operations of language access services to LEP patients across HHC.
  • Establishing performance and quality improvement measures to improve quality of care, health literacy, and to identify and address healthcare disparities.

Language Access Services
A Limited English Proficient (LEP) individual is a person who does not speak English as his/her primary language and who has limited ability to read, write or understand English at a level that permits the person to interact effectively with health care providers and social service agencies. Addressing this barrier is directly related to HHC’s goals of providing quality health care and ensuring patient safety. According to an analysis of U.S. Census Bureau data, slightly more than one-half of the adult population in communities served by HHC speaks a language other than English at home and 25% of HHC’s patients are Limited English Proficient. On average, HHC provides interpreter services in more than 160 languages per year. In Fiscal Year (FY) 2011, HHC’s facilities provided more than 600,000 language interpretation requests in more than 160 languages at an estimated cost of more than $5 million. Between FY 09 and FY 11, these figures grow to more than 1.5 million language interpretation requests at an estimated cost of more than $10.4 million, The most prevalent languages other than English include: Albanian, Arabic, Bengali, Chinese (both Mandarin and Cantonese), French, Haitian Creole, Hindi, Korean, Polish, Russian, Spanish, and Urdu. Of these languages, Spanish is the most prevalent accounting for 67% of interpretation requests. HHC’s corporate wide initiatives to address persons who are LEP include:

  • Implementing the language identification “I Speak” card program;
  • Installing appropriate bi-lingual and multi-lingual signage;
  • Expanding interpreter capacity;
  • Translating written materials; and
  • Designating a Language Access Coordinator at each facility who is responsible for overseeing the provision of LEP services.

Installation of appropriate signage in multiple languages within HHC facilities has been a priority. The signage informs HHC’s patients that interpreter services are available, free of charge, and guides them to the appropriate locations within each facility.

Expanding interpreter capacity is an ongoing process for all health care facilities and it is particularly challenging given the demographic changes that occur and the resources required. In collaboration with the City University of New York and several other organizations, HHC worked to establish the CUNY Healthcare Interpreter Program 4 years ago. This program builds workforce capacity by training bilingual and multilingual CUNY students and HHC staff to serve as qualified healthcare interpreters to help limited English speakers. Just this past week, a graduation ceremony was held at Lincoln Medical and Mental Health Center for the third year of graduates from this program. Fifty-four (54) students who speak Spanish, Polish and/or French successfully completed a 45 hour program that focuses on interpreting clinical information, recognizing and dealing with ethical issues and cultural conflicts, and understanding clinicians’ roles and expectations. Students also learn medical vocabulary and use role-playing exercises to master interpreting skills that emphasize accuracy, which is essential for patient safety.

Interpreter services include both in-person (also called face-to-face or proximal) interpreters and the use of telephonic interpreter services. The in-person interpreters are both HHC staff who have been trained and tested to qualify as medical interpreters and professional qualified agency interpreters. Those agencies are selected during our bid process with very strict quality criteria to ensure best service to our diverse patient population. Telephonic services are used for languages not covered by in-person interpreters, or if the patient is uncomfortable with having a third person in the examination room. These services are available on a 24 hour basis. All HHC facilities have an interpreter hotline that will allow staff to dial in seamlessly and efficiently (from any phone in the facility), to access both telephonic and face-to-face interpreter services.

Another component of HHC’s LEP efforts is the translation of written materials, such as informed consent forms and patient instruction and education materials, into the languages most spoken by our patients. In 2003, HHC launched a CLAS intranet website for staff on which all key documents, patient instructions and education material, and links to additional patient care information in multiple languages are available for staff to download.

New York City’s public healthcare system strives to provide high quality health care services in a linguistic and culturally appropriate manner to a diverse patient population. I thank you for the opportunity to provide testimony. I am happy to answer any questions that you may have.



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