Standard readiness: Targeting patient-provider communication

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Standard readiness: Targeting patient-provider communication

After reading this article, you will be able to: 

  • Identify key areas hospitals should focus on for patient-provider communication requirements 
  • Describe how to establish a baseline for compliance with patient-provider standards
  • Discuss the right questions to ask when establishing the effectiveness of a hospital’s patient-provider communication policies


Editor’s note: Each month, an expert from The Greeley Company will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. This month’s article is by consultant Laure Dudley, RN, MS, CSHA, senior consultant with The Greeley Company. Have a question for our experts? E-mail Senior Managing Editor Matt Phillion at


Are you questioning your readiness for the recently approved Joint Commission patient-provider communication standards? Although these standards don’t have a firm implementation date when they will actually be scored, they are available and surveyors will be assessing for compliance in 2011. 

At first glance, it might seem as if these standards are merely a reemphasis of what is already required. However, The Joint Commission feels that they go beyond what is currently expected and truly cover the safety and quality of care provided on a patient-specific basis, not just simple culture issues or obtaining language services. So it’s worth taking a look at the standards in the context of the 93-page implementation guide which was released in August 2010.

Upon review, the standards focus on three key areas: 

  • Effective identification of needs and the support required to meet patient goals
  • Addressing patient-specific needs through family, cultural, and religious support, to name a few
  • Aggregation of patient-level data for use to improve patient care


The standard requirements

The standard requirements are as follows: 

  • In the patient care delivery process, the new standard (PC.02.01.21) mandates that the hospital determines the best way to effectively communicate when providing care and services. The two elements of performance (EP) will be scored at the “A” level, according to The Joint Commission’s Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. 

- EP 1 focuses on the hospital identifying the patients’ written and oral communication needs, including preferred language for healthcare literacy purposes and how this will be determined (e.g., process through admitting or nursing). An emphasis is placed on thinking broadly about the different barriers in communicating with a patient, such as the use of hearing aids, glasses, and alternatives for speech when intubated in the ICU. The hospital must be prepared to address appropriate patient communication issues. 

- EP 2 addresses communicating with patients in a way that meets their needs, which might include pictures, diagrams, or videos. 

  • In patient rights, there is an emphasis on providing written (translation) and oral (language) services (RI.01.01.03).

- A new note under EP 2 (provision of language and interpreter services) includes a focus on determining which documents and languages need translation based on the population served. For example, the language line is a great tool, but there can be delays in providing the service, and it is limited to audio. Use your baseline assessment to determine whether you are appropriately fulfilling the needs of your patients based on the volume of those served. 

- The interpreter needs to be able to assist in relating to medical issues, so a translated document should not simply be handed to a patient without providing additional support. On-the-fly translations can lead to errors, and someone who has only conversational language skills may not have the proficiency to relate on medical issues. This would preclude using housekeeping or office staff who speak the language but are not necessarily trained to relay health information. This EP’s scoring remains at the current “C” level.

  • Staff qualifications must be determined by the hospital (HR.01.02.01).

- Note 4 has been added under EP 1 (job responsibilities include staff qualification) requiring the hospital to define proficiency and provide training for interpreters and translators. The hospital must make a judgment on how to address proficiency and training to relate with healthcare issues. Some hospitals currently require translators to be certified or at least to complete an educational course. You need to be able to articulate your process in this area.

  • Standard RC.02.01.01 in record of care includes EP 28, requiring data collection of race and ethnicity, and a new note under EP 1 includes noting the patient’s, guardian’s, or designated advocate’s preferred language for discussing healthcare issues to support the role of the medical record in handoffs. The intent is for hospitals to evaluate the aggregated data, understand cultural issues, and plan for services (e.g., determine what documents should be translated based on your data).

- EPs 28 and 29, scored at the “A” level, have been added to RI.01.01.01 focusing on access of a “support individual” to be present for the patient as much as possible while prohibiting discrimination. This forces hospitals to review visitor restriction policies. Do you currently allow friends or same-sex partners unlimited visits in the ICU? Review your restrictions to see whether they need revision. Of course, exceptions to the “open-access designee” will need to be determined for important considerations such as infection control or safety reasons.


Establish the baseline

The Joint Commission recommends that organizations determine how best to meet their patients’ needs by performing a self-assessment of their current practices. Hospitals must decide how to handle these issues for the populations they serve and use the data to make improvements. How do you currently determine whether you are doing a good job in meeting your patient’s health literacy needs? If you haven’t already assembled a team to look at this issue, it might be worthwhile because you will be asked about your progress to date. A multidisciplinary approach is ideal as you think about all the areas of the care process the patient touches in the course of service delivery in your institution.

Along with reviewing your practices, it’s important to keep in mind the federal requirements such as the civil rights laws and the Americans with Disabilities Act along with state and local mandates for meaningful language access and cultural competence. Can you demonstrate your assessment and evaluation related to answering the following questions?

  • Are needs being met at all stages of the patient care process for potential support, such as during admission, while undergoing treatment, or services including end of life?
  • Who likely needs assistance in your organization?
  • Are patient rights related to interpreters, accommodations, or assistive devices conveyed in a manner that is understood by the patient? 
  • What measures are already in place to support patient-specific needs such as interpreter or sign language services? 
  • What happens if the patient needs assistance in understanding healthcare information? How is the process implemented?
  • How are individual patient needs identified?
  • How does staff interface with these patients? 
  • How are needs monitored on an ongoing basis for effectiveness? 


Editor’s note: Join us next month for the continuation of this article. Readers will find additional questions and a discussion on the plan for implementation.