Fifth National Conference on
Quality Health Care for Culturally Diverse Populations
Building the Essential Link between Quality, Cultural Competence, and Disparities Reduction

October 17-20, 2006
Renaissance Seattle Hotel, 515 Madison Street, Seattle, Washington

Presented by
Drexel University School of Public Health Center for Health Equality
Resources for Cross Cultural Health Care
US Department of Health and Human Services, Office of Minority Health

Preconference B Workshops

Workshop B-1: A comprehensive and multifaceted approach in redesigning Interpreter Services in a large public hospital system and professional and team development techniques for interpreter staff

Alameda County and San Francisco County are two of the most diverse counties in the nation. Thirty percent of Alameda County’s 1.4 million residents are foreign born and approximately 19% of the population over the age of 5 years indicates that they speak English “less than very well.” Thirty-five percent of San Francisco County’s 732,000 residents are foreign born and approximately 24% of the population over the age of 5 years indicates that they speak English “less than very well.” Both Alameda County Medical Center (ACMC) and San Francisco General Hospital (SFGH) are the safety net hospitals in their respective counties and have had established Interpreter Services Departments for over 20 years.

With the increasing health care costs combined with the increase demand for language services from growing diverse communities, Alameda County Medical Center and San Francisco General Hospital entered into a collaborative effort to share language resources between two major public hospital organizations and implement a video conferencing interpretation (VMI) program. Since Year 2003, the VMI project has been steadily implemented at both ACMC and SFGH with encouraging progress. To date, ACMC and SFGH have completed over 7,000 video-conferenced interpretations, collectively, and have piloted the exchange of interpreter services over video conferencing technology. Through the implementation process of the video conferencing technology enhancement, both ACMC and SFGH have redesigned the organizational service provision model for accessing interpreter services, and redesigned the interpreter services department.

This intensive training session will include the following components and learning objectives:

1. Implementing a Video Conferencing Enhancement for medical interpretation. This new technology has been examined by many health care institutions for its applicability in medical interpretation, health care provision for LEP patients, and patient acceptance. ACMC and SFGH have tested and incorporated video conferencing as an interpretation modality since 2003. As the ACMC and SFGH implementation experience is shared, participants will:Learn the basic technological needs (“the nuts and bolts”) to implement a video conferencing program in their organizations.
   b. Experience the training provided to clinical staff and identify key points and “take-aways” to make this training successful.
   c. Experience the training provided to interpreter staff including video presentation skills, and how to effectively clarify with patient and clinical staff through video communication for effective interpretation.
   
   
2. Re-designing the organizational service provision model for accessing interpreter services: Increasing cultural awareness among staff and building awareness for the need of utilizing interpreters for Limited English Proficient (LEP) patients continue to be major issues across many health care organizations across the country. In this segment participants will:
   a. Receive tips on how to make language access changes successful in clinical areas.
   b. Learn key barriers experienced by ACMC and SFGH, positive strategies used to address these areas, and lessons learned from both success and missteps.
   c. Have opportunities to discuss various barriers in their own organizations and collectively discuss ideas and strategies through a facilitated discussion.
   
   
3. Re-designing the interpreter services department into a more efficient service model. The professional development of medical interpretation is a relatively young profession and does not currently benefit from the traditions and formal guidelines found in more established professions. Current interpretation programs have experienced independent development evolutions with varying levels of staff skill, training, and experience resulting in the organizational challenges that accompany them. In this segment, participants will:
   a. Learn key components in the redesign process of transforming a traditional in-person interpretation model to a coordinated interpretation services incorporating in-person, phone, and video conferencing technology.
   b. Discuss barriers and challenges experienced in the redesign process, including areas service model change, professional development, and team development.
   c. Learn recommended elements for professional development, team development and change in an interpreter services program.
   

   Janice Chin, M.P.H. has been working in public health for the last 10 years in community based settings as well as hospital settings in issues including to increase access to care for underserved populations, mainly limited English proficient (LEP) populations requiring linguistic and culturally appropriate health care services. Ms. Chin is currently the Program Administrator of grant programs, including the Video Conferenced Medical Interpretation (VMI) Program, and the Interim Director of the Interpreter Services Department at Alameda County Medical Center. In the past two years, Ms. Chin has been working on service redesign of the ACMC interpreter services department, the organization’s language access delivery model and the implementation of the VMI project.
   

   Gloria Garcia-Orme, RN, MS, Interpreter Services Department, San Francisco General Hospital
   Bruce Occena, MPH, MBA, Health Access Foundation

Workshop B-2: Responding to cross-cultural conflict using the Intercultural Conflict Assessment Inventory

Too often, diversity and cultural competence training programs stop at raising awareness without imparting any real skills to participants. This workshop offers participants some of the latest knowledge in the emerging field of cross-cultural conflict resolution. Better still, it offers participants a tool that can be used for personal and organizational skill-building in addressing and resolving cross-cultural conflict with patients and culturally diverse employees.

The workshop will provide a foundational overview of ten core cross-cultural value differences that can either impair or enhance cross-cultural communication. Following the seminal work of noted cultural anthropologists, these crucial factors include distinctions between: individualism and collectivism; achieved vs. ascribed status; task vs. relationship orientation; high-context vs. low context communication; linear vs. lateral mental processes; emotional neutrality vs. expressiveness; direct vs. indirect approach to conflict; egalitarian vs. hierarchical approach to the sharing of power; monochronic vs. polychronic approach to time and internal vs. external locus of control.

Building on this foundation, we will administer the Intercultural Conflict Style Assessment Inventory to participants. This relatively new instrument was created and validated via internationally controlled studies by American University Professor Mitch Hammer, a national and international expert on cross-cultural communication and conflict. (In addition to his published works and academic credentials, Dr. Hammer has served as a consultant to assist the federal government resolve international hostage crises!) The simplest way to describe the Intercultural Conflict Style Assessment Inventory is that it is like the Myers Briggs of Intercultural Conflict.

By taking the Intercultural Conflict Style Assessment Inventory participants will understand their personal, (largely unconscious), and culturally influenced conflict style and how their conflict style differs from three other prototypical conflict styles from around the world. In addition, while avoiding stereotypes about these groups, participants will gain valuable insights into the predominant cultural conflict styles for various racial and ethnic populations in the U.S. and throughout the world. By understanding their own personal cultural conflict style and those of other cultures, participants will learn which of their cultural biases about conflict and its resolution will likely come into play in cross-cultural interactions. In particular, participants will learn why familiar U.S. conflict resolution approaches, such as that made popular by the Harvard Negotiation Project (“Getting to Yes”) are ineffective in resolving cross-cultural conflict.

Finally, we will discuss how the Intercultural Conflict Style Inventory can be used with health care audiences to better understand how to resolve intercultural conflict in the workplace and with culturally and linguistically diverse patients. Participants will learn about the most common causes of intercultural conflict at work, how to diagnose the predominant cultural conflict style in their organization and how to resolve conflict with colleagues and patient in each of the four major conflict styles. The tool is also helpful in diversity-related team-building exercises.

David Hunt is the President and Chief Executive Officer of Critical Measures. Critical Measures is a management training and consulting firm that assists employers to harness the power of diversity to create more productive, profitable and inclusive workforces.

Over time, David has developed national expertise on diversity-related matters in law, business and medicine:

• HealthCare: A sought-after national speaker on issues of racial and ethnic disparities in health care and the legal aspects of providing culturally and linguistically appropriate care, David recently served as the public policy chair of the Minnesota Immigrant Health Task Force. Much of Critical Measures current work is in the area of cultural competence in health care. Its health care clients include industry-leading health insurers, managed care organizations and hospitals. Together with physician partners from the Harvard Medical School, Critical Measures has created, licensed and sold the nation's first e-learning programs on cross-cultural medicine for continuing medical education credit for doctors and nurses.
• Business: Over the last ten years, David has worked with leading American corporations such as Microsoft, American Family Insurance and 3M on diversity matters. Recently, he helped Critical Measures land an exclusive national contract to provide diversity training to the National Collegiate Athletic Association (NCAA) and its member institutions.
• Law: David has worked with the Minnesota Supreme Court, the Minnesota Court of Appeals, the Minnesota Attorney General’s Office, area law schools and the Minnesota State Bar Association to provide training programs for attorneys on diversity and the elimination of bias in the legal system.
  Prior to working in the diversity field, David worked as an attorney, specializing in employment and civil rights law. A former adjunct professor at the William Mitchell College of Law, David has mediated employment law matters for the EEOC and the Minnesota Office of Dispute Resolution as part of the Minnesota Human Rights Mediation Program.
• A writer, speaker and current events commentator, David has appeared on the McNeill-Lehrer News Hour and published numerous articles. He received his B.A. from Carleton College and his J.D. from the William Mitchell College of Law. David and his wife Joan have three children: Kate (21), Sarah (19) and Samuel (2).

Workshop B-3: A teaching guide to methodology in cross-cultural care: case-based illustrations of clinical and ethical fundamentals in culturally competent care

An interactive case-based workshop aimed at training providers around questions related to culture and health care. Attendees will be provided with training materials that have been developed from actual cases and used in training settings for students in Medicine, Nursing and Social Work. Trainees will receive training materials, bibliographic resources and the challenge to participate in a broad range of discussion around how to define, teach and effectively carry out culturally competent care.

Target Audience: Health Care Providers, health educators and medical anthropologists

Case sources and studies: Cases are drawn from university teaching hospitals and ambulatory clinics, as well as community primary care and mental health clinics. In each case documentation has included direct care, reviews of clinical records, interviews with involved patients and clinical staff as well as follow-up for a minimum of three years (with the exception of case six). Cases three and six are based on videotaped interactions.

1) “Start out in Intensive Care, your team got a sick man off the surgical service last night:” Day one of your month as inpatient attending you find a respirator-dependent Nigerian Man with aggressive T-Cell Lymphoma transferred to your ICU service. His oxygenation plummets at every attempt to get him off the respirator. His family declines an outside interpreter and opposes disclosure and truth telling around both the nature of his illness and the risks of chemotherapy.

Training Focus: Negotiation and therapy in the face of culturally disparate views of truth telling, disclosure and informed consent.

2) Week-end rounds: You’ve been given 22 cards with brief identifying and clinical infor-mation. One finds you in the room of a Scandinavian widow hospitalized for a Pulmonary Embolus who is nearing discharge on oral anticoagulants. She appears anxious and startled, but continues to assure you as the cross-covering internist that everything is “fine.”

Training focus: Discussion of culture bound views of fundamental issues – in this case, interviewing techniques and widowhood. The case gets to the core of what’s ‘cultural’ about mainstream assumptions.

3) “My cousin said that you are willing to listen:” An elderly Spanish American man self-refers after frequent visits to a University Hospital ER for abdominal pain. Extensive evaluations focused on his history of prior abdominal surgeries and complications, insulin dependent diabetes, coronary artery disease and hypertension. The ER visits fail to reveal a diagnosis. A previously undisclosed history and traditional diagnosis emerges.

Training focus: Incorporating traditional views in clinical methodology and therapy.

4) Unrelenting somatic complaints in a mental health clinic: A 44 year-old Cambodian woman with Post Traumatic Stress Disorder and unrelenting, undiagnosed abdominal pain. The patient focuses exclusively on her abdominal pain. Repeated visits to a University-based medical clinic and a community mental health unit lead to a presumptive diagnosis of PTSD. She is consistently unable or unwilling to disclose details of her life experience.

Training focus: Methodology in cross-cultural settings.

5) An inpatient referral for undiagnosed Right Upper Quadrant pain: A 52 year-old fluently bilingual, mild mannered Inuit man, a minister, trapper and prominent community leader, transfers to a University Hospital following two sequential stays in Alaskan hospitals. He is on methadone maintenance for undiagnosed RUQ pain. At day 10, the docs suggest another invasive test. He becomes agitated, disruptive and threatens to sign out. When the call comes asking you to see this patient, you can hear him shouting in the background. And you …

Training focus: Interviewing methodology, the implications of disparate language, and fundamentals about oral traditions.

6) Seeking permission to remove a colonic polyp. A Cree-speaking woman visits the gastroenterology clinic, undergoes an interview, a colonoscopy and a radiographic study of her large bowel. Discussion follows about the need to remove a polyp. The trained interpreter, who has worked for years with this specialist, undertakes a variety of uncued, independent interactions with the patient.

Training focus: Issues related to interpreter standards and responsibilities, team functions and informed consent.

Participants will receive fully developed training materials for two cases, bibliographic materials for all six and carefully outlined resource/training guides for the other four cases. It is the trainer’s expectation that at least four of the cases will be completed in a three-hour session. Depending on make-up of the participants, cases will be selected and may be substituted (from an unpublished case book) to fit the participant interests. Case presentations and discussion will be carried out in an interactive mode, with the cases read aloud, discussed by the group and supported by power point and DVD materials. Videos described will not be shown but may be accessed by interested clinicians and/or researchers once permission-based demands are met.

Bob Putsch, MD is senior advisor to the Cross-Cultural Health Care Program and a clinical professor of medicine at the University of Washington School of Medicine. As one of the founders of CCHCP, he helped develop training programs for medical interpreters as well as a cultural competency training curriculum used at various sites such as the CDC, various medical colleges, state and local agencies. On occasion CCHCP's work has involved negotiation around community-institution relations in both hospital and in medical school environments. CCHCP has researched issues ranging from perceived racism in health care encounters and non-Western ethical systems around truth telling and disclosure, informed consent and death and dying, to cultural competence in Medicaid Managed care. Advocacy by CCHCP led to the development of the National Council on Interpretation in Health Care.

He has been a primary care internist since 1968 and joined the primary care staff at Pacific Medical Center in 1978 where he also did nephrology for a number of years. An attending on University of Washington teaching services at PMC and at Providence Hospital, Seattle, he ran their cross-cultural rounds for ten years. In 1992 he began as a consultant in psychiatry at Asian Counseling and Referral Service (a 14 language API community mental health clinic). He has published articles on Cross-cultural communications, Ghost Illness, Methodology and Language in Cross-cultural care, the meaning of death to adolescents in an American Indian community, ethical dilemmas arising from differences in class, culture, language and power, and end-of-life decision making. Brief papers provide commentary about a variety of issues in current medical literature. A recent paper incorporating issues of language, class and cross-cultural communications is focused on teachers in family medicine training programs, a second is a report on applications of the CLAS Standards at five of six sites studied around the country, while a third describes ties between health care inequities, power, institutional policies/process and dysfunction in health care education.

Dr. Putsch left his internal medicine practice in 2003 and is semi-retired. He continues teach at the School of Medicine and to see patients at Asian Counseling and Referral Service. His panel (restricted to patients with PTSD and affective disorders) consists of patients who are entirely limited English proficient speaking Khmer, Vietnamese, Hmong, Lao, Mien and Samoan. Current work and publications that are underway include a paper on Navajo divination practices, a commentary on dealing with victims of war and a case book that looks at the care of individual patients as well as a 15 year experience brokering relationships between a subset of communities and a major medical institution.

Workshop B-4: Cultural Competence in Health Care: A Train-the-trainers workshop

Many challenges face cultural competence trainers today. For example, the professional diversity of participants means that clinicians, support and front-line staff, administrators, staff interpreters and dual role interpreters may all attend at once. Other challenges include a lack of national training standards, brief formats (most cultural competence "trainings" last from 45 minutes to one day), the changing face of the field, funding shortages, the lack of research that demonstrates a correlation between such training and reduced health disparities, and the need for a national organization to support trainers in the field.

What can cultural competence trainers do to present quality training that enhances an organization's ability to provide quality care and reduce health disparities? Why is the field in disarray? Which types of training work best? What objectives should a basic training target? How well does current research assess such training? Which teaching techniques are most effective?

Cultural competence trainers need straightforward answers to all these questions. The goal is to provide an overview of the cultural competence training field today. By the end of the workshop, participants will: 1) discuss the core elements of an effective one-day training in cultural competence; 2) demonstrate basic knowledge of evidence-based curricula in cultural competence; 3) select teaching strategies and tools best suited to the needs of their participants.

Teaching approach: the workshop would be limited to 20 qualified participants who have given prior cultural competence trainings. Each participant would be instructed to submit by email, prior to the workshop, a resume, a one-page sample curriculum and a one-page summary of tips and tools for cultural competence trainers. Workshop time will focus on interactive discussion, film footage, small group activities (for example, groups will select a list of "top 10" strategies from among those submitted by participants followed by a large-group discussion of their "top 10" lists), and a demonstration role play. Take-home tools: a) a 2-page summary of outcomes-based research literature on cultural competence training; b) a list of resources for cultural competence training; c) a collection of the handouts submitted prior to the workshop by participants.

A bilingual Canadian, Ms. Bancroft has lived in eight countries and speaks five languages. After studies at eight universities around the world, she holds a BA and MA in French linguistics from Quebec City and advanced language certificates from Spain, Germany, and Jordan. With over 20 years in the field of language training and language access, she has offered university courses on translation, interpreted in health care and human services, directed a language bank of over 200 interpreters and translators, taught at immigrant schools, offered bilingual direct services and established a health program for immigrants. Since 2000 she directs Cross-Cultural Communications, an agency devoted to cultural competence and language access. She has given scores of trainings in cultural competence and interpreting across the U.S. and is co-author of a 40-hour community interpreting curriculum for bilingual staff. Ms. Bancroft provides research, technical assistance and training for federal, state and local government agencies, national and regional nonprofits and health care organizations. She has authored an environmental scan of interpreter standards of practice for NCIHC and three train-the-trainers manuals in cultural competence.

Workshop B-5: Reaching your Audience: Developing messages and working with the media to address racial/ethnic disparities

Objective: Provide health professionals an overview of the main ethnic media markets and basic tactics to work with health reports to effectively disseminate key messages.

The power of ethnic media: an overview

• Provide an overview of the national networks and magazines
• Provide an overview of key ethnic media markets (AA = Atlanta, Hispanic= Miami, and so on…)
• Provide an overview of the networks, national

What media wants, crafting compelling media angles

• Discuss what is hot in the media right now, what are those health topics they are craving for
• Discuss the difference between ethnic media and GM media
• Discuss the importance of having good spokespeople, subject-matter experts, testimonials, etc.

Building working relationships with ethnic media

• Basic PR tools (advisories, releases, desk side meetings), when to use each one, and why
• Basic pitching, PR etiquette when calling reporters…
• Provide real life samples of what to do/what NOT to do…etc.

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