Cross-Cultural Communication Strategy: Improve Your Health System’s Patient Satisfaction Scores with Training and More Inclusion

// By Jill Mead //

With patient experience increasingly recognized as connected to a host of measures, including patient outcomes and your bottom line, it’s essential to reach all of your target populations with education and messaging that resonate with people’s cultural backgrounds and native languages.

More than ever before in our history, U.S. hospital and health system financial health is tied to patient experience. The Centers for Medicare and Medicaid Services (CMS) directly tie reimbursement rates to Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) scores. The concept of “patient as consumer” continues to grow. Like consumers in every other industry in today’s Yelp-review society, patients can help or harm hospitals, physicians’ offices, clinics, and the like — through online reviews, social media posts, and of course, word of mouth, too.

Additionally, more data emerges every day establishing the strong connection between positive patient experience and improved clinical outcomes, increased patient adherence to medical advice, improved patient safety practices, and lower utilization of unnecessary health services. Positive patient experience is necessary not only for the health and well-being of your patients, but also for your bottom line.

Exploring the Nuances of Patient Experience Initiatives

Patient experience initiatives are rewarding, but often challenging. The challenge grows exponentially when you add language and cultural barriers. Creating a positive patient experience for Limited English Proficient (LEP) patient populations is no easy task. We know the law requires providing qualified interpreters and translated vital medical documents; interpreting and translating form a solid foundation for creating positive patient experiences for LEP populations. But language access is not the only factor in patient experience for LEP patients and their loved ones.

Beyond interpreting and translating, two factors that U.S. hospitals and health systems sometimes overlook can have a major impact on patient experience for these populations:

1. Staff cultural competence
2. Wayfaring tools

Staff Cultural Competence

Culture plays a major role in how individuals interact with health care providers as well as how they view the importance of personal health practices. Let’s demonstrate with a real-life example experienced by my own company.

Traditional Western culture looks at time much differently than many developing or agriculture-based cultures. For the vast majority of health care providers and staff members, an appointment at 1 p.m. means one must arrive at or before 1 p.m. or be considered “late,” which is not acceptable. But in many developing and/or agriculture-based cultures, “clock time” is not king. Rather, time is looked at in terms of activities. So 1 p.m. would be “after morning chores and the midday meal have been completed.” Since things can happen that take more or less time during any given morning, a person arriving anywhere between noon and 3 p.m. would not be considered “late.”

The activity time concept is so foreign to most U.S health professionals that encountering patients who come from activity time cultures can cause immense frustration. My company actually experienced this firsthand following an influx of Somali refugees in our community. Health care providers reported unusual numbers of patients arriving late. Yet the patients themselves were baffled as to why the doctor wouldn’t see them, and were upset at being told to reschedule. On the other side, my own company was frustrated by an increased number of Somali-language interpreters arriving late. A little research revealed the cultural root of the problem, and once we understood the context, this insight helped us to craft some key solutions:

• Pre-appointment reminder calls
• Helping patients put calendar events on their phones to remind them when to leave to go to their appointment (not just the start time of the appointment)
• For patients using public transportation, helping to plan out the route, which buses/trains/etc. the patient needs to take, and what time the patient needs to be at the bus stop/train station/etc.
• Explaining that the doctor’s activities are on a strict schedule, which means the patient must arrive by the time on the clock (i.e., explaining in terms of activity time for the doctor)

How Different Perceptions Lead to Misunderstandings

Misunderstandings frequently result when individuals from two different cultures perceive the same set of facts differently. The time orientation issue is one with “only” indirect clinical repercussions: Patients may miss important appointments and don’t reschedule. But other cultural disconnects can result in more direct negative health outcomes. For example, individuals from hierarchal societies, like traditional Asian cultures, often will not question or challenge individuals in positions of authority — like doctors — and may simply agree and then fail to comply with a doctor’s instructions. This can have devastating results when patients don’t take prescription medications, don’t follow pre-surgery instructions, or even fail to show up for necessary surgery.

Training Matters

Overcoming cultural conflict in health care is at once simple and difficult. There is really only one solution: cultural training. It is deciding what to include in that training that makes it difficult. No health care system can be expected to train all its staff to be experts in all the various cultures of the world. When designing an effective training system, health care professionals should include:

1. General Cultural Awareness Training: Half the battle in training for cultural awareness is helping people “get out of their own heads” and teaching them to understand that not everybody thinks or believes the way that they do. Once one realizes that others see things in entirely different ways based on cultural differences, two things happen. First, that person opens his/her mind to learning about other cultures. Second, that person will add “could there be a cultural reason this is happening?” to his/her thought process.
2. Specific Cultural Training for the Most Commonly Encountered Cultures: Hospitals and health systems will encounter patients from some cultures more than others based on geography and local populations. For example, only about 10 areas in the U.S. have large populations of Somali immigrants, including Columbus, Ohio (within my company’s service area). It’s important to offer training regarding the cultures of the most commonly encountered LEP populations. It’s also important to note here that while the Spanish language may be the number-one non-English language in just about every location within the U.S., “Spanish” is a language — not a culture.
3. Cultural Resources for Less Commonly Encountered Cultures: When staff members encounter a patient from a culture they have no experience with, and their “could there be a cultural reason this is happening?” alert goes off, they need someplace to turn for help. Keeping a list of links to cultural resources and/or a library of cultural reference materials will help staff avoid cultural mistakes. But beyond this, staff often have a wonderful resource available: the language interpreter. Pursuant to interpreter ethics guidelines, health care interpreters are expected “to be cognizant of and able to alert both the patient and the provider to the impact of culture in the health care encounter.”

Wayfaring Tools

Showing up to a medical facility to seek care is often stressful. When that facility has five different entrances to a complex of interconnected buildings with five stories of offices and departments, just getting to the specific place the patient needs to be can add a whole separate layer of stress. The helpful wayfaring signs aren’t so helpful when they’re written in a language the patient cannot understand. The same is true whether it’s an old-fashioned sign on the wall or a touchscreen kiosk or smartphone/table navigation app.

The struggle to navigate large medical facilities starts before the patient even sets foot in the building. Ever try to figure out where to park at a large medical complex? Think about the directional signs. At best, they were probably in English and Spanish, and more likely only in English. Ever try to plan your route using maps available on a facility’s website? That’s a great option as long as the website is available in your language.

Wayfaring tools that allow patients and friends/family to navigate the halls of a medical complex certainly improve the patient experience. But having signs in 10 or 15 different languages just isn’t practical. So how can health care facilities assist LEP patients in a way that makes sense practically? Here are a few ways some of my clients have overcome the wayfaring/language barrier:

1. Placing picture-based maps online and at registration: Maps with pictures to direct patients to the most commonly needed areas of the facility can eliminate the language barrier. Most health care icons are recognizable regardless of language. Having the same picture/icon at the entrance to each department or area on the map is, of course, important for this method.
2. Using number-based maps with multilingual keys: Many maps identify departments, buildings, etc. with a number or letter and then provide a legend or key. With this system, a single map with numbers/letters can have legends/keys in a variety of languages. Mark the entrance to each department or area on the map with its corresponding letter/number code.
3. Offering pre-appointment planning: Where a trip to a medical facility is scheduled ahead of time, a pre-appointment phone call with an interpreter can not only remind the patient about the appointment, but talk him/her through where to park, which door to enter, which elevator to take, etc.
4. Providing multilingual written patient guides: More than just interpreters, multilingual patient guides meet a patient and his/her loved ones at the registration desk and act as a personal guide through the complex hallways of the facility.
5. Having access to live patient guides: Even if the guide does not speak the patient’s language, using an interpreter (often by phone) to determine where the patient needs to be and to ask the patient to “follow me” allows an English-speaking staff member to physically guide the patient to the correct location.
6. Planning digital wayfaring: Many hospitals and facilities are moving toward digital wayfaring. GPS-like, location-aware systems would, of course, be most effective for LEP populations if localized into the patient’s own language. But even without this, these systems can use symbols to indicate “turn left,” “turn right,” “go up the elevator to floor 3,” etc.
7. Using colors and shapes to supplement words: A more old-school, but still effective, method for limiting the need to read English is using colored lines on the floor or walls and colors or shapes at intersections. These tools can help both LEP and English-speaking patients find their way.

Making a Difference for Patients and Health Systems

When health systems make a concerted effort to provide all of the resources that patients from all cultures need, you can truly make a significant difference for patients, families, and for your organization, too. In fact, providing qualified language interpreters and translated documents, along with offering cultural competency training for staff members, and implementing the latest best practices in wayfaring, forms a solid base for ensuring a positive patient experience for LEP patients and their loved ones. As a result, your patient satisfaction ratings will likely rise, you’ll see better outcomes, and you’ll ultimately notice a difference in your bottom line.

Jill Mead serves as in-house compliance counsel for Vocalink, Inc., a full-service language solutions company offering interpreting, translation, and localization for health care, legal, public service, financial, manufacturing, and corporate clients. For more information, visit www.vocalink.net.