Being Properly Inclusive — A Lesson from the Joint Commission

Alternate title: Best Practices in the Care and Nurturing of LGBT People.

Every once in a while, someone or some body does something that has to be applauded. When they do or it does, it should be acknowledged for the positive that may come out of it…if only to encourage more of similar behavior in others.

The Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which is the accrediting agency for hospitals nationwide, has released a new field guide (pdf): Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community.

Financial assistance in preparing this guide was obtained from The California Endowmnent.

The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

All patients, regardless of social or personal characteristics, should be treated with dignity and respect and should feel comfortable providing any information relevant to their care, including information about sexual orientation and gender identity. Every hospital and health care organization is unique and no single approach works best, but The Joint Commission encourages hospitals to adopt a combination of the strategies and practices discussed and to use these examples as a foundation for creating processes, policies and programs that are sensitive and inclusive of LGBT patients and families.

—Jerod M. Loeb, Ph.D., executive vice president, Division of Healthcare Quality Evaluation, The Joint Commission

The Joint Commission offered Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals in 2009, but acknowledges in the new field guide that the publication had less than satisfactory results. It was considered not specific enough to be put into implementation. Hence they produced the new publication.

LGBT patients face other barriers to equitable care, such as refusals of care, delayed or substandard care, mistreatment, inequitable policies and practices, little or no inclusion in health outreach or education, and inappropriate restrictions or limits on visitation.

Earlier this year the Joint Commission updated its standard for patient-centered communication to include prohibition of discrimination based on sexual orientation, gender identity or gender expression. According to this update, all patients are to be assured of access to a support person of the patient’s choice.

The field guide is broken down to address the following five areas: Leadership; Provision of Care, Treatment, and Services; Workforce; Data Collection and Use; and Patient, Family, and Community Engagement.

Let me say here that although the material to follow is designed for an audience of hospital administrators, I think it would prove relevant to the administration of any for-profit or non-profit enterprise or organization, which is why I am including it. With any luck it will ring somebodies bell.

Leadership

Create new policies or modify existing policies to integrate unique LGBT patient needs:

Develop or adopt a nondiscrimination policy that protects patients from discrimination based on LGBT status.
Ensure equal visitation.
Institute a policy identifying the patients’ right to identify a support person of their choice.

Demonstrate commitment to inclusivity for LGBT patients and families.

Monitor organizational efforts to provide more culturally competent and patient- and family-centered care to LGBT patients, families, and communities.
Develop clear mechanisms for reporting discrimination or disrespectful treatment.
Develop disciplinary processes that address intimidating, disrespectful, or discriminatory behavior toward LGBT patients or staff.
Identify an individual directly accountable to leadership for overseeing organization efforts to provide more culturally competent and patient-centered care to LGBT patients and families.
Appoint a high-level advisory group to assess the climate for LGBT patients and make recommendations for improvement.
Identify and support staff or physician champions who have special expertise or experience with LGBT issues.

Respect for all is interwoven throughout our organization. We clearly communicate to our providers and staff what our mission means in an open manner. This is our policy, when we are here, this is who we are and what we do-we check our biases at the door.

-Vice President, Human Resources at a Midwest hospital

Provision of Care, Treatment, and Services

Create a welcoming environment that is inclusive of LGBT patients.

The hospitals’ nondiscrimination policy/patient’s bill of rights should be prominently displayed.
Waiting rooms and other common areas should be LGBT-friendly.
Create or designate unisex or single stall restrooms.
Ensure that visitation polices are fair and nondiscriminatory.
Honor/nurture all patients and their families.

Two of my friends are a gay couple, but until I took the LGBT training, I didn’t realize how much they worry. I mean, it never occurred to me that they might not comfort each other-even hold hands-in the hospital because someone might see them and treat them badly. It broke my heart when I heard this, and when I asked my friends about it, they confirmed it. I can’t imagine not holding my husband’s hand if he were in pain, and as a nurse, I want to make sure gay people do not have to worry about supporting each other in my hospital!”

-Nursing Supervisor, Kansas

Avoid assumptions about sexual orientation/gender identity.

Refrain from making assumptions about a person’s sexual orientation or gender identity based on appearance.
Be aware of misconceptions, bias, stereotypes, and other communication barriers.
Recognize that self-identification and behaviors do not always align.

Facilitate disclosure of sexual orientation and gender identity but be aware that this disclosure or “coming out” is an individual process.

Honor and respect the individual’s decision and pacing in providing information.
All forms should contain inclusive, gender-neutral language that allows for self-identification.
Use neutral and inclusive language in interviews and when talking with all patients.
Listen to and reflect patients’ choice of language when describing their own sexual orientation and how the patient refers to their relationship or partner.

Provide information and guidance for the specific health concerns facing lesbian and bisexual women, gay and bisexual men, and transgender people.

Become familiar with online and local resources available for LGBT people.
Seek information and stay up to date on LGBT health topics. Be prepared with appropriate information and referrals.

When I was training as a nurse, I encountered my first transgender patient. The nurse I was shadowing was clearly uncomfortable and it was making everyone else uncomfortable, particularly the patient. I finally pulled her aside and said, “This is terrible; your feelings are so obvious that it is affecting the patient. If you can’t handle this you should ask another nurse to step in.” I was a little worried to speak up but just felt so badly for our patient. The nurse was apologetic but admitted she was uncomfortable because this was the first transgender patient she had seen. Now that I am a nurse manager, I make sure to present different scenarios with hypothetical patients in our meetings and talk through how we can best provide care in each situation. In this way, everyone is prepared and ready to treat any patient who walks through the door.

-Nurse Manager, Midwest hospital

Workforce

Ensure equitable treatment and inclusion for LGBT employees.

Protect staff from discrimination that is based on personal characteristics, including sexual orientation, gender identity, or gender expression.
Equalize health care coverage for same-sex-partnered and transgender employees.
Equalize all other hospital benefits.

Demonstrate commitment to LGBT equity and inclusion in recruitment and hiring.

Add LGBT-inclusive language to job notices.
Attend LGBT job fairs, advertise in LGBT publications, and conduct outreach with LGBT groups.
Include the hospital’s LGBT-inclusive benefits and policies in recruitment and hiring materials, both online and in print.
Train human resources employees on general LGBT workplace concerns and the hospital’s LGBT-inclusive nondiscrimination statement, benefits, and policies.

Educate staff on LGBT employee concerns.

Provide information about LGBT workplace concerns in all appropriate training.
Offer LGBT training to key audiences.
Distribute to human resources staff online and print information about LGBT workplace concerns.
Develop a plan to address the unique needs of transgender employees.

Incorporate LGBT patient care information in new or existing employee and staff training.

Vary methods used to provide training.
Update training and educational material on a regular basis.

Support staff development initiatives to maximize equity and inclusion for LGBT employees.

Support an LGBT employee resource group (ERG), which can assist LGBT employees, provide expertise to hospital staff, and raise awareness of LGBT concerns throughout the organization.
Support forums for employees to freely and openly discuss any LGBT-related questions or concerns in a group setting to encourage learning.
Commemorate LGBT events, such as Pride Month and National Coming Out Day, with educational programming, mentoring and networking opportunities, and other awareness raising activities.

It always seemed to me like we were a reasonably good place for LGBT people to work. This is a pretty gay-friendly area, and we don’t get that many formal complaints. But I set up a workshop on LGBT workplace issues because we were doing other diversity workshops for our managers. That’s when I heard about the microinequities’ LGBT people face-feeling like they can’t mention their families, can’t bring in vacation photos, can’t say what they did over the weekend, and feeling like they have to overperform because they’re LGBT. I had no idea how much they worried about other people being uncomfortable, or losing out on opportunities and raises. It was really eye-opening for our managers, and now we really track what’s happening for LGBT employees and let them know they’re welcome here.

-Human Resources Director, Pennsylvania

We haven’t had a lot of transgender patients yet, but we arranged training because we wanted to be ready. I’d heard that transgender patients have bad experiences, but I didn’t know what that meant until we had the presentation. When I heard about transgender patients being pointed at, having people ask them rude questions, being told to use bathrooms in other buildings, I realized we had to make sure our staff wouldn’t do those things. No one should have to go through that-no one. Now we talk about transgender patients in our HIPAA training, we’ve created unisex bathrooms, we’ve given our admitting staff and nurse managers information about transgender patients, and we’re going to bring the presenter back.

-Patient Relations Director, Connecticut

Data Collection and Use

Identify opportunities to collect LGBT-relevant data and information during the health care encounter.

Identify a process to collect data at registration/admitting.
Identify a process to document self-reported sexual orientation and gender identity information in the

medical record.
Ensure that the disclosure of sexual orientation and gender identity information is voluntary.
Train staff to collect sexual orientation and gender identity data.
Ensure that strong privacy protections for all patient data are in place.
Add information about sexual orientation and gender identity to patient surveys.
Use aggregated patient-level sexual orientation and gender identity data to develop or modify services,

programs, or initiatives to meet patient population needs.

Use available population-level data to help determine the needs of the surrounding community.

Use national- and state-level data on sexual orientation and gender identity to develop initiatives that address the health concerns of LGBT patients.
Conduct focus groups or interview community leaders, including LGBT community members and leaders, to

identify changes in the demographics and needs of the surrounding community.
Conduct community needs assessments that include LGBT demographics.

Patient, Family, and Community Engagement

Collect feedback from LGBT patients and families and the surrounding LGBT community.

Conduct confidential patient satisfaction surveys that include questions regarding sexual orientation

and gender identity.
Ask LGBT patients and families about staff responsiveness to their needs during care planning and treatment and include whether and how these needs were accommodated.
Encourage community input and collaboration by establishing a community advisory board.
Engage LGBT organizations to provide feedback on internal and external written material and policies to ensure that they are LGBT-inclusive.

Ensure that communications and community outreach activities reflect a commitment to the LGBT community.

External Communications

Utilize the hospital Web site to communicate information about available services, programs, and

initiatives to meet unique LGBT patient and family needs.
Expand marketing efforts to include LGBT audiences by publishing in LGBT media.

Community Outreach

Designate an individual or create a committee to address LGBT community outreach activities and to

establish or maintain ties to community partners.
Ensure that existing community outreach activities are LGBT-inclusive.
Establish partnerships with community health centers and other health care facilities in your community.
Engage state hospital associations and state departments of health to determine areas of potential collaboration with regard to LGBT health issues.
Consider participating in cultural competency programs for students in medical, nursing, and other allied

health programs.
Consider sponsoring, participating, or providing educational resources to gay/straight alliances at local colleges or high schools.

Offer educational opportunities that address LGBT health issues.

Provide educational programs and forums that support the unique needs of the LGBT community.
Engage external LGBT community organizations in the development and review of existing educational

programming to ensure that it is LGBT-inclusive.

There are also appendices addressing the accreditation standards of Environment of Care (EC), Human Resources (HR), Information Management (IM), Leadership (LD), Provision of Care, Treatment, and Services (PC), Record of Care, Treatment, and Services (RC), Rights and Responsibilities of the Individual (RI), and Transplant Safety (TS).