Language Differences as a Barrier to Quality and Safety in Health Care: The Joint Commission Perspective

When a patient sees a clinician member of a treatment team, the clinician uses the available knowledge base (derived from her education and training, the literature, experience, decision-support systems, and protocols) to decide what data to collect about the patient and how to collect them. The clinician and other members of the team collect these data through conversations with the patient and the patient’s family, observation of the patient, a physical and mental examination, laboratory testing, and imaging. The treatment team then synthesizes these patient-specific data with the evidence-based information in the available knowledge base to create new information: the patient’s diagnosis and prognosis and, in the dialog with the patient, a treatment plan. Finally, the team disseminates this newly created information to the patient, the patient’s family, other members of the treatment team, other professional caregivers, pharmacists, insurance companies, and others. Dissemination occurs through oral communication (e.g., in conversations with the patient, patient’s family, and health care professionals), through writing (e.g., in consent forms, instructions, educational materials for patients, and in notes and instructions for other professional caregivers and pharmacists), and through electronic transmission (e.g., in pharmacy orders, insurance claims, and computerized, patient-accessible personal health records).

This collection of data, transformation of data into information, storage of data and information, and dissemination of information are the key processes that comprise information management. Today, in health care, much of this information management is in the form of oral and written communications between team members, patients, and patients’ families. The more the care is patient- and family-centered, the more frequent the communication with the patient and the patient’s family to understand the patient’s perspective and to involve the patient in the treatment team itself.

When patients with limited English proficiency are treated by physicians and other health professionals who are proficient only in English, 3 factors converge to create a “triple threat” to effective communication. First, the language differences themselves are a barrier to effective communication. Unfortunately, this language barrier is often not immediately evident. Instances in which patients identified themselves as (reasonably) proficient in English, but were not, have been reported, and a Joint Commission study found physicians and hospital staff who believed themselves to be sufficiently proficient in another language, but were not.1 Both the patient and the clinician can underestimate the language barrier between them.

Second, cultural differences—which are often associated with language differences—are a barrier to effective communication. One’s culture affects one’s understanding of a word or sentence and even one’s perception of the world. To learn a language is not the same as understanding a culture—even those who share a common native language may not share a common culture. And not everyone born in the same place and speaking the same language necessarily shares all the features of a common culture. Therefore, there is a risk of either underestimating the effect of cultural differences or of stereotyping individuals by their culture. Both will interfere with the effectiveness of communication.

Third, low health literacy is a barrier to effective communication.2 Low health literacy in patients may be associated with language and cultural barriers, but is also found in patients who are proficient in English and who share the common U.S. culture. This latter group may be especially at risk of having their low health literacy go unrecognized. When language or cultural barriers are identified, it often leads the clinician to explore whether the patient understands her oral or written communication. But when the patient speaks the same language and is of the same culture as the clinician, too often the clinician assumes that the patient—in the absence of questions—understands. Many clinicians have belatedly discovered that a patient is functionally illiterate: the patient cannot read or write (general literacy), let alone understand the clinician’s medical jargon or complex instructions (health literacy).

In an increasingly multilingual, multicultural society, providing safe, high-quality health care requires overcoming these 3 barriers to effective communication with patients and their families. When the Joint Commission first developed standards that required an organization to address the language needs of patients, it was in the context (subsequently bolstered by federal regulations) of the patient’s right to be fully informed about his or her care. Later, the need to communicate effectively was recognized as an element of the quality of patient care. Today, effective communication—which takes into account language, cultural differences, and health literacy—is seen as a prerequisite to safe health care. Communication problems are the most frequent root cause of serious adverse events reported to the Joint Commission’s Sentinel Event Database,3 and a Joint Commission study found that when patients suffer adverse outcomes from medical errors, the outcomes are more serious in limited English proficiency patients than in English-speaking patients.4 Patient rights, quality of care, and patient safety each in itself is sufficient to justify a commitment to effective communication. Together they make effective communication in health care obligatory—it is a critical component of the health care itself.

Yet often those health care organizations that are struggling to implement practices to reduce language, culture, and health literacy barriers to communication do not know which practices are most effective.1 And even when effective practices are known, their implementation in a reliable, sustainable, and efficient manner is challenging. This JGIM Supplement begins to provide some evidence-based solutions to this challenge. But more is to be learned, and the solutions that have been identified often must be adapted to individual organizations.

As a physician’s or other clinician’s office, clinic, hospital, or other health care delivery setting focuses its attention on improving the safety and quality of patient care, these observations generate a set of principles:

As the Joint Commission focuses the spotlight of its standards and accreditation process on patient safety and quality of care, these principles will guide its approach to removing communication barriers related to language, cultural differences, and low health literacy, as well as communication barriers arising from physical factors such as hearing, speech, and vision, and from health care interventions such as intubation. But do not await Joint Commission actions—if the goal of providing safe, high-quality care is to be achieved, the obligation of health care professionals and organizations to address linguistic, cultural, and health literacy barriers to patient communication is immediate.