When Words Fail

As the political haggling over immigration vividly demonstrates, America is growing ever more pluralistic. Ignoring the realities of ethnic diversity is unwise at any level of the nation’s service economy. If the service you provide is healthcare, though, a tone-deaf ear for language differences could lead directly to a poor, even tragic, outcome.

Consider the highly publicized case of Willie Ramirez. In 1980, this Spanish-speaking teenager from southern Florida complained to doctors at an area hospital that he felt dizzy and had a headache. Ramizez and his family members insisted he was “intoxicado.”

Doctors presumably likened that word to “intoxicated,” ran some tests and concluded the young man was the victim of an intentional drug overdose. That diagnosis proved tragically wrong.

The Spanish word “intoxicado” can also mean feeling dizzy or nauseous. Ramirez had actually suffered an intracerebellar hemorrhage that soon left him a quadriplegic. In the malpractice trial that followed, a jury awarded Ramirez $71 million.

“A growing body of research is documenting that a variety of patient populations experience decreased patient safety, poorer health outcomes and lower quality care based on race, ethnicity, language, disability and sexual orientation,” said Christina L. Cordero, PhD, MPH, an official at the nation’s premier health care accrediting agency, the Joint Commission.

Seeking to reverse that trend, The Joint Commission plans to make enhanced cultural and ethnic diversity awareness an accreditation must for all healthcare organizations.

New Communication Standards
The Ramirez case is not the only documented example of a patient with limited English proficiency (LEP) suffering a tragic outcome.

In 2005, researchers collected data on English-speaking and LEP patients from six hospitals and analyzed it using patient safety criteria from the National Quality Forum. They found that 49 percent of adverse events suffered by LEP patients caused physical harm whereas only 29.5 percent of adverse events to English-speaking patients resulted in physical harm.1

And a study of pediatric patients linked language barriers between LEP families and emergency department physicians with higher rates of resource utilization and longer ED lengths-of-stay.2

For years, the Joint Commission has had an accreditation standard in place (HR.01.04.01, EP 5) to orient staff on sensitivity to cultural diversity. By 2008, though, Joint Commission officials clearly felt more was needed.

With funding from The Commonwealth Fund, the Joint Commission created a multidisciplinary panel to further the cause of effective communication, cultural competence, and patient- and family-centered care in hospitals.

The result, a set of new Patient-Centered Communication Standards, were approved in December 2009, released to the field in January 2010, and will be published in the Joint Commission’s 2011 Comprehensive Accreditation Manual for Hospitals. Compliance with the new standards will become part of the accreditation process sometime on or after January 2012, according to Dr. Cordero.

Qualified, Competent Interpreters
Among other changes, the new standards will require hospitals to:

  • Ensure that medical records include each patient’s race and ethnicity. “Hospitals can determine when and how this information is collected,” said Dr. Cordero, associate project director of the Joint Commission’s Division of Standards and Survey Methods.

  • Allow family members, friends or others to be present for emotional support. “While the concept of access to a support individual is not intended to dictate hospital visitation policy, it is intended to raise awareness of the need for visitation policies that are inclusive of those whom the patient identifies as important,” she said.

  • Ensure that individuals who interpret or translate for LEP patients are qualified and competent — which may require language proficiency assessment, education, training and experience.

Regarding this last requirement, a number of agencies now offer certification for the nation’s estimated 15,000 to 17,000 medical interpreters. The National Board of Certification for Medical Interpreters launched its National Medical Interpreter Certification program in 2009 and planned to have its first 500 interpreters certified by this year. Another agency, the Certification Commission for Healthcare Interpreters, planned to launch its own certification for medical interpreters this fall.

Unlike interpreters, however, rank-and-file hospital providers should not require any additional training to comply with the new patient-centered communication standards, Dr. Cordero believes.

She said feedback so far from hospital executives regarding the new standards was “strongly positive.”


1. Divi C, Koss R, Schmaltz S, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60-67.

2. Hampers L, Cha S, Gutglass D, et al. Language barriers and resource utilization in a pediatric emergency department. Pediatrics. Jun 1999;103(6 Pt 1):1253-1256.

For further guidance on cultural diversity, caregivers can access the Joint Commission’s Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals at

Michael Gibbons is an editor at ADVANCE.

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