In the 2001 Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, equitable care was identified as one of the 6 domains of health care quality. Without equitable care, health systems cannot purport to be providing safe, high-quality care. It has now been 20 years since the US Department of Health and Human Services Office of Minority Health released the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (or National CLAS Standards). The enhanced National CLAS Standards issued in 2013 provide 15 action steps that aim to improve health care quality, reduce health disparities, and advance health equity by establishing a framework for health and health care organizations to serve the nation's increasingly diverse communities. The National CLAS Standards are guided by the Principal Standard: "Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs."1 This commentary illustrates how Johns Hopkins Medicine (JHM) operationalized an approach to develop a health equity focus based upon the 3 domains of the National CLAS Standards-Governance, Leadership and Workforce; Communication and Language Assistance; and Engagement, Continuous Improvement, and Accountability.
GOVERNANCE, LEADERSHIP, AND WORKFORCE
JHM advances and sustains organizational governance and leadership that promote CLAS and health equity through policy, practices, and allocated resources. For example, the JHM Office of Diversity and Inclusion, which provides the infrastructure for the health system's diversity, inclusion, and health equity activities, was recently renamed the Office of Diversity, Inclusion, and Health Equity (ODIHE) to reflect the Office's health equity work.2 The ODIHE oversees Diversity Councils at all of the entities across the health system and currently supports 3 employee resource groups (ERGs)-the Hopkins Diaspora, Hopkins Familia, and Hopkins Veterans-with plans to launch an LGBTQ & Allies ERG, an Asian American & Allies ERG, and a Disability & Allies ERG in the near future. Throughout the year, the ODIHE commemorates various heritage months and recognizes and highlights underrepresented minorities across the health system that exemplify excellence and exhibit JHM core values (Achievers' Awards) during their respective heritage months. A religious observance tool kit was developed in recognition of the importance of the role of religion to the workforce, patients, and their families.
The ODIHE educates and trains governance, leadership, and the workforce in culturally and linguistically appropriate policies and practices on an ongoing basis through (1) system-wide unconscious bias and diversity awareness training and (2) development of a train-the-trainer program of local facilitators at the various entities. In addition, policies are regularly reviewed, such as appearance standards (dress/hair/headdress), patient identification, transgender transition, and bathroom policies, as well as disability accommodations for employees, to ensure that unintended inequities do not exist.
COMMUNICATION AND LANGUAGE ASSISTANCE
JHM Language Services provides patients and families who have limited English proficiency (LEP) access to qualified medical interpreters for more than 250 languages through a variety of modalities, including in-person, over the phone, and video remote interpretation services. In addition, JHM Language Services identifies bilingual providers and staff, assesses their competency in the target language, and then grants them qualified bilingual provider/staff status. JHM Language Services also supports patients who are blind or have low vision and those who are deaf or hard of hearing. The COVID-19 pandemic exposed communication as an equity issue. In response to the pandemic, information on COVID-19, testing, public health measures, and patient instructions from telemedicine visits was translated into the 5 most common languages spoken by patients across our health system-Arabic, Chinese, Korean, Russian, and Spanish. As the pandemic evolved, our clinicians identified LEP Latinx immigrants in our community as a particularly vulnerable population with enhanced communication needs across the continuum of care. Through collaboration with the JHM ODIHE, Language Services, Human Resources, and Centro SOL (Center for Salud/Health and Opportunities for Latinos), we deployed qualified bilingual clinicians, social workers, and staff to help support communication needs for our Spanish LEP patients with COVID-19.
ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY
The JHM Health Equity Advisory Committee serves as the overarching structure that facilitates the establishment of culturally and linguistically appropriate goals, policies and management accountability and infuses them through the organization's planning and operations (Figure).
The JHM ODIHE will be formalizing a collaborative partnership with the JHM Armstrong Institute for Patient Safety and the Quality and JHM Office of Population Health in order to conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities. The ODIHE aims to develop the required infrastructure for accurate and consistent capture of patient demographic data in the electronic health record across the health system, including race, ethnicity, and language (REaL), sexual orientation and gender identity (SOGI), and disability status. To this end, the ODIHE partnered with JHM Language Services to conduct REaL data collection training for COVID-19 Call Center, Access Services scheduling, and Johns Hopkins Community Physicians Centralized Scheduling staff as well as Emergency Department registration staff from April to July 2020. As JHM conducts regular assessments of community health assets and needs and uses the results to plan and implement services that respond to the cultural and linguistic diversity of populations in our service area, the JHM organizational health equity operational team will be crucial team members participating in these assessments. Through its Patient and Family Advisory Councils (PFACs), including a Latino Family Advisory Board (which addresses the unique needs of Spanish-speaking patients and families) and Community Advisory Boards, JHM partners with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. Furthermore, the PFACs have prioritized increasing diverse representation as a goal. The ODIHE works in close collaboration with the Johns Hopkins University and the Johns Hopkins Health System Offices of Organizational Equity as well as the Patient Relations Department to create conflict- and grievance-resolution processes that are culturally and linguistically appropriate in identifying, preventing, and resolving conflicts and complaints. Finally, the ODIHE regularly communicates the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public via quarterly reports to JHM executive leadership, an annual report, weekly and monthly newsletters, and community briefings.
CONCLUSION
Health systems play a critical role in modeling standards of exceptional, equitable, and high-quality care using the CLAS Standards framework, which articulates the important need for a diverse and inclusive workforce and governance structure to attain health equity for the most vulnerable communities. Just as we have learned and indoctrinated new protocols and prevention strategies during the COVID-19 pandemic to promote patient safety, we need to similarly indoctrinate CLAS strategies into all of our clinical operations to promote patient safety. Our patients' lives are depending on this and depending on us!
REFERENCES