AONE Diversity in Health Care Organizations Toolkit

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The following resource related to culturally
-
sensitive care for Burmese patient populations was
submitted for the purpose of distributing to AONE members as part o
f the AONE Diversity in
Health Care Organizations Toolkit.


Submitted by:


Texas Health Presbyterian Hospital Dallas

Contact persons:


Cole Edmonson
, MS, RN, FACHE, NEA
-
BC


Vice President of Patient Care Services and Chief Nursing Officer

Deb Maitre, MS,

RNC
-
OB, C
-
EFM

Director of Women’s and Infant’s Services

Dallas, TX




With Special Thanks to the Additional Interprofessional Patient
-
centric Process Design Work Team
Members:



Dale Leach, Director, Patient & Guest Services/Community Relations



Mina Kini, D
irector, Diversity Management



Jazz Patterson,

BSME, LSSBB
,
Performance and Productivity Engineer,
Decision Support



Clint Abernathy, MBB, Director, Performance and Productivity



Julie Anderson, IRC



Kari Brasseiero, IRC



Luke Saw, IRC



Chris Brooks,
RNC, MSN
,
Nurse Manager,
Neonatal Intensive Care Unit



Marjeta Daja,

MBA/MHA, Diversity Consultant, Diversity



Debra DuBois, RN, Women’s Health Center



John Engelhard,
MDiv., BCC, Senior
Chaplain, Pastoral Services



Kendra Henderson,
BSN, RN
, Nurse Manager,
Newborn/Adm
ission
Nursery/Lactation



Nancy Hetherington, Admitting



Kristi Ingram, Manager, Medical Records



Ruby Manuel, Advocate Patient Language Services, Guest Services



Patti Marks, RN, Supervisor, Labor and Delivery



Cathy Nakashima,
MLS, MBA, Coordinator
,
Medical
L
ibrary



Molly Montgomery,
MLS, MS,
Medical Librarian,
Medical
Library



Wilma Montz,
BA Speech Communications, Director, Special Programs
Refugee & Empowerment Services Division,
Cathol
ic

Charities



Melissa Morton,
ADN
-
RNC
,
Nursing
Supervisor,
Newborn & Admiss
ion
Nursery/Lactation Services



Elsa Phelan, MSW, LBSW, Director, Community Outreach and Health
Improvement



Sandra Pinkerton,

Ph.D., CCMEP
,
Director,
Director, Curriculum
Development & Distance Learning, Texas Health Research and Education
Institute



Kelli
Raibick,
MSN, RN, IBCLC
,
Nurse Manager, Post Partum



Erin Smith,
RNC
-
OB, BSN, JD
,
Nursing Supervisor,
Labor & Delivery



Jean Tan,
RN, BSN, CEN
, Emergency Department



Rosa Belgard, MS, RN, Manager, Nursing and Patient Education



Nancy Quelland, RN, MS, BC, Educ
ation Coordinator, Nursing Education



Teresa Cannon,
IT Solutions



Randy Brinson, RN, Manager, Clinical Information Systems



Amanda Bodwell
,

DNP, RN, CPNP
,
Pediatric Nurse Practitioner/Supervisor,
Pediatric Clinic



Judy Travis,
RD, MHA, MBA, Director, Ambulat
ory Services



Myesha Bryant,
NRCMA, Medical Assistant,
Pediatric Clinic



CaSandra Williams,
MAOM, CPSO, CHEM, CHSP, CSE, MPO,
Director,
Security


Texas

Health Presbyterian Hospital Dallas (T
exas
H
ealth
D
allas
) is one
of
fourteen hospital
entities owned by Te
xas Health Resources

(Texas Health)
, a single premier health care
organization in North Texas
.

We combine clinical expertise, advanced technology, and
compassionate, individualized care to deliver the best possible outcomes for the patients we
serve
.
We

are proud to be a team working together to live out

our faith
-
based values: respect,
integrity,
compassion,

and excellence
.
This translates to Texas Health being a brand of trust
.

Internally, we express the essence of our brand as the Promise:
Individua
ls Care for Individuals,
Together
®
.
Externally, we express the essence of our brand as
Healing Hands. Caring Hearts.
sm



In 2009, refugees from Burma emerged as the second largest limited English proficiency
population at
Texas Health Dallas
. An interpr
ofessional Diversity Project Team identified the
problem, established project goals, and developed strategies and tactics to provide safe,
effective, culturally
-
sensitive care for this Burmese population
.
The initial focus of this initiative
centered on B
urmese patients’ experiences with their prenatal, perinatal, and postpartum care
.
The following materials in this Diversity Toolkit include:




Case Study



Project Overview of Care Coordination for Burmese Population at Texas Health Dallas



Policy Statement R
elated to Patient Education



Process Map



Patient Education Tools



Staff Education Tools and Care Delivery Processes



I.

Case Study


By: Debra DuBois, MS, RN, Certified Nurse Midwife, Texas Health Pre
sbyterian Hospital
Dallas


KT is a 26 year old refugee from
the refugee camps in Malaysia
.
She arrived in the US
5/20/10.


Her first appointment at W
omen’s
H
ealth
C
enter (WHC)

was

on

7/7/10
.
Our best
estimate was that she was about 36 weeks along
.
I saw her that day for her first
a
ppointment
.
I used the Languag
e Line for interpretation with a male interpreter
.
She was
seen by the Social Worker that same day
.
She denied any depression in the past or that
time
.
She also didn’t tell us about history of seizures that later came up.


She ended up delivering on 7/
13/10 without complications
.
Her family called 911 when she
had a seizure on 8/2/10
, and she was brought to Texas Health
Presbyterian Hospital
Dallas

E
mergency
D
epartment.

In

the meantime
,

at
the
WHC
,

we started with a female Burmese
interpreter.


She is

Burmese herself and culturally knowledgeable.


On 8/11/10
,

KT came to
WHC for her postpartum check up
.
We give all
postpartum

patients the
Edinburgh
Postnatal Depression Scale (
EPDS
)

depression questionnaire at their visits
.
The questions
are very perso
nal and don’t translate well, particularly over the phone to a third party
.
Through the female, onsite interpreter
,

the questions were explained and the patient
scored a 19
.
The SW and the interpreter spoke with KT and she stated a plan to take her
two c
hildren (a newborn and
a
two
-
y
ea
r
-
old) into another room and not hurt them
.
She
then stated that she was going to take the kitchen knife and kill herself.


The SW called KT’s Refugee caseworker
,

and he and a team from ADAPT crisis met with KT
and her hus
band at their home
.
The female interpreter did not attend this meeting
.
At this
time
,

KT recanted her story
.
She was later evaluated by a Psychiatrist and admitted to
Green Oaks
(a local Psychiatric inpatient facility)
for “wanting to die
.


She was see
n again
by
the Texas Health Dallas team

on 8/25/10 and taking antidepress
a
nts
.
Her EPDS score
was 8 on this visit.



II.

Project Ov
erview of Care Coordination for
Burmese Population at Texas Health Dallas


The Burmese population emerged as the second largest

population with limited English
proficiency at Texas Health
Dallas.
Several challenges and barriers surfaced related to
providing interdisciplinary care for these patients, including:




Lack of timely access to Language Line Interpreters (available as a c
ontracted
service)



Variable health literacy levels of these patients in their native language



Limited understanding and acceptance of Western medicine practices



Lack of coordinated communication across the care continuum


According to Jacobs and colleagues

(2004), individuals with limited English proficiency (LEP)
that have interpreter services available are more likely to receive and follow through with
preventive care and medical office visits and were also more likely to get their prescriptions
filled
.
Individuals with LEP may experience mistrust, less satisfaction with care, and even be
at greater risk for medical errors (Divi, Koss, Schmaltz, & Loeb, 2007).


With that in mind, an interprofessional project team sought to improve these patients’
health u
nderstanding and their satisfaction with care.


The project goals were to:



Provide safe care for Burmese patients



Provide appropriate patient education for these patients regarding their care



Provide appropriate education about the Burmese culture for THD

staff



Identify community resources to provide continuity of care for Burmese patients



Seek and receive funding to support aspects of this project



Serve as an integrated provider and coordinator of care across the continuum


The business benefits of the pr
oject were identified as:



Improved quality of care and service for these patients



Increased patient safety



Improved patient satisfaction (demonstrated by 25% improvement in patient
satisfaction scores)



Decreased non
-
value added time staff spend in providin
g care/service for patients



Improved staff satisfaction


References:


Jacobs, E., Shepherd, D. S., Suaya, J. A., & Stone, E. L. (2004)
.
Overcoming language barriers
in health care: costs and benefits of interpreter services.
American Journal of Public
He
alth, 94
(5), 866
-
869.


Divi, C., Koss, R. G., Schmaltz, S. P. & Loeb, J. M. (2007)
.
Language proficiency and adverse
events in U.S. hospitals: A pilot study
.
International Journal for Quality in Healthcare,
19
(2): 60
-
67.





III.

Policy Statement


The following policy statement serves as an example of
Texas Health Dallas
’ commitment to
patient/family
-
centric education and provides a sound framework for this care coordination
project for better serving Burmese populations a
t T
exas
H
ealth
D
allas
.


According to our “Patient and Family Education” policy, the “
Assessment, identification of
needs, and planning of education should consider barriers/limitations affecting the
readiness/ability to learning including but not limited t
o:

a.

Cultural/religious beliefs and values.

b.

Physical, emotional, cognitive issues/deficits.

c.

Literacy,
education,

and language barriers.

d.

Age and lifespan issues.

e.

Motivation to learn.

f.

Financial implications of care.

g.

Learning preferences.




IV.

Educational Materi
als


T
exas Health
developed and
i
mplemented
an education program for system employees
entitled “Considerations for the Caregiver: Providing Culturally Sensitive Care.

T
he
focus
included topics related to cultural sensitivity and compassion and respect an
d consideration
for personal preferences based on cultural and religious beliefs
.
Differences between
practitioners’ (rooted in Western biomedical culture) and patients’ (rooted in cultural
beliefs and knowledge of Western biomedicine) expectations for ca
re and services were
reviewed
.
The session encouraged practitioners to accept cultural differences without
judgment and to avoid stereotyping patient populations, even when these individuals and
families are members of the same culture
.
Practitioners wer
e encouraged to avoid
ethnocentrism and carefully investigate and assess patients’ values, beliefs, and health
habits before developing a treatment/care plan.


Exercise the “platinum rule”


learn how others want to be treated, rather than assuming
they w
ish to be treated according to our own cultural values, beliefs, and norms
.
Some key
factors to consider in relating to Burmese populations:



They are often quiet and less talkative than Western populations.



They may not be comfortable questioning those in

authority, such as physicians.



Burmese patients generally consult members of their own communities about
health care matters and related decisions.



Burmese women are modest and may avoid visiting the doctor’s office or hospital to
avoid exposure during ph
ysical examinations
.
Uncovering parts of their bodies to
strangers, especially male health care providers, may make these women feel
ashamed.



Being direct is considered rude in Burmese culture
.
Loud speech and aggressive
body language may make Burmese pa
tients uncomfortable.



Displays of anger and/or disagreement are not respected by the Burmans.



Burmese individuals are addressed by their given names, and married couples do
not share the same name.



Birthdays are not recognized by the Burmese and may be lis
ted on official
documents as January 1
st

accompanied by an estimated birth year.



Not all patients from Burma speak Burmese, and there are many dialects
.
Karin and
Chin refugees may speak and understand the Burmese language but prefer not to
speak the lan
guage of their military oppressors.



Approximately 90% of Burmans are practice Theravada Buddhism as their religion
.
Buddhist beliefs include the belief in
karma



the idea that good and bad events can
be attributed to past actions
.
Buddhists also believe

in reincarnation, the rebirth of
the soul and body
.
Each individual has personal responsibility for seeking salvation
and achieving
nirvana.



Equanimity and mindfulness are central to the dying process and may be valued
more than measures to manage sympto
m control
.
Patients may prefer to be alert
and avoid clouding of their senses as opposed to being pain free.



Decisions are usually made by consensus.



Direct eye contact is not considered polite, except by those of equal status.



Folding one’s arms in front

of one’s body when talking is a sign of respect.


Access to health care involves two
-
way communication, understood by both parties
.
Language barriers limit access to care and patients’ ability to understand, accept, and follow
recommended treatment plans
.
Explaining all types of procedures and the reason for them
to Burmese patients is very important, also including that the procedure was ordered by the
physician and that the person performing the procedure has been specially trained to do so
.
Employees

are reminded not to utilize family members or other employees as interpreters
.
Interpreters must be trained and/or designated as official interpreters.


When providing services to Burmese patient populations some common questions to ask
them include some

or all of the following:



What do you think is wrong with you?



How long have you had this problem?



Do you know anyone else with the problem?



Are there certain foods that you prefer over others?



Apart from me, who else do you think could make you feel bette
r?



Why do you think you are sick
?
(Listen carefully for clues for supernatural, non
-
biological, or religious references to causative factors)



What does your sickness do to you?



Do you think there are therapies that would make you feel better that I might
not
know about?



What medications, herbs, or treatments have you used since the beginning of your
symptoms?



Which of the following do you believe would be the best approach for your follow
-
up care?



If it’s possible to offer options, then provide them with
as many choices as possible,
including oral vs. injectable medications, nutritional therapy plans, etc.


Texas Health hospitals are committed to ensuring that all patients; including those with
communication challenges such as LEP receive the support and i
nformation they need to
access services, communicate with health care staff, and make informed decisions about
their care and treatment.


As part of
Texas Health
’s “Culturally Competent Care” series, an “Educational Fact Sheet”
related to Burmese refugee p
opulations provides important information

for clinical staff
and physicians

when

caring for patients from
these
diverse cultures
.
An example is
attached as a separate file at the end of this Toolkit.


In addition, a number of educational tools were develo
ped for clinicians to use in assisting
Burmese patients and families in navigating the health care system
.
Examples of those are
also included.



IV. Job Descriptions/Performance Measures


A job description for a Language Assistant to address the unique n
eeds of Burmese patients
is included as a separate attachment at the end of this Toolkit.



V.

Program Outcomes


The data shown in this graph represents the affect of the Burmese project efforts on
Language Line use in the Women’s Health Center.


Texas Health

Dallas demographic data
has shown a consistently increasing trend of Burmese cases per month in 2010.


Even with a
rising volume of Burmese patients, the ultimate result of initiatives such as the patient
tours, graphical tools, and improved patient data
collection has been a decrease in the need
for the Language Line in this area.


There is also a significant drop in usage from the month
of August to September. This is a direct result of the implementation of the Language
Assistance on August 11, 2010, w
hich provides face
-
to
-
face interaction with these non
-
speaking patients and gives the Women’s Health Center a more responsive method of
communicating with patients.


This Language Assistant has resulted in an additional cost in
manpower, but the residual e
ffects of having a live person who can translate in the clinic
have been tremendous.





VI.

Attachments

A.

Educational Fact Sheets for Clinicians

B.

Educational Tools to assist Burmese pat
ients and families

C.

Job Description for Language Assistant














A. Educational Fact Sheets for Clinicians










B. Educational Tools to assist Burmese patients and
families



















C. Job Description for La
nguage Assistant