The face of the U.S. has changed and in all likelihood your population base has also changed too. In 1950, there were nine white people under age 40 for every person of color. By 2000, the ratio was 1.5 white people for each person of color (United States Census Bureau, 2000). Moreover, the U.S. Census Bureau calculates that by 2042, U.S. residents who identify themselves as Hispanic, black, Asian, American Indian, Native Hawaiian and Pacific Islander will together outnumber non-Hispanic whites (Bernstein & Edwards, 2008). The United States today has broader language diversity than the whole of Europe. Fifty-two million Americans speak a language other than English at home, and 23 million (12.5% of the total population) report having limited English proficiency (LEP) (United States Census Bureau, 2005).

These changing demographics reflect the broader economic and political changes occurring worldwide. Specifically, the declines of Communism, open borders and open trade have all led to large-scale immigration and migration in most developed countries. The effects of these global changes are impacting local communities. Health care organizations need to keep pace with local demographic changes in order to develop the necessary competencies to provide high-quality care for patients with ever greater cultural and language diversity. In this step we suggest five action steps that you can undertake to learn more about the language communities you serve and to identify the dangers inherent in not responding to the language needs of these communities.
  
Action Step 2.1:  Conduct an internal assessment to determine the languages spoken by patients served and the services they seek. Use formal (e.g. needs assessments, chart review, health plan statistics) or informal (e.g. staff interviews/surveys) approaches. Be sure to search not only for the number of patients who speak a language other than English but also for those who are hearing impaired or unable to read and write. This assessment is also an early opportunity to see how your organization is currently responding to patients who prefer to receive information in languages other than English and to identify gaps that prevent you from gathering and/or creating solutions
 
Action Step 2.2:  Conduct an external assessment to analyze the language needs of the community you serve and identify future or changing demand for non-English materials. Learning about demographic and workforce changes in the larger community can help you identify the response capacity your organization may need to develop to meet the language and communication needs of your community.  It can also help to determine whether your patient population reflects the overall community you serve. External data sources on your local and regional demographics and language preferences may include U.S. Census data, county or state health departments, newspaper stories, regional business forums and hospital quality groups.

Action Step 2.3: Adopt practices and create systems to routinely collect language data. Require collection of patients’ preferred language on reporting tools and make this information known during the course of care. Develop a mechanism to train staff to remain alert to language barriers. For example, consider requiring notation of the language preference of patients on adverse reporting forms or including a standard question about the need for interpreters on consent forms or other similar commonly used forms. Promote patient safety by reviewing these reports to identify trends and set priorities. Also see Collecting Race, Ethnicity, and Language Data: A How-To Guide, a Web-based toolkit developed by Health Research and Educational Trust (HRET) with recommended approaches for the collection of race, ethnicity and primary language information (HRET, 2008).

Action Step 2.4: Designate overall leadership responsibility for raising awareness of the linguistic needs of the organization. Formulate executive leadership responsibility to promote a general understanding of the diverse communication needs of patients in your organization, collect and disseminate the findings of your assessments and pave the way for building response capability. These champions can be armed with your internal and external data to paint a demographic and linguistic picture of your population, with examples of associated risks of poor communication. This heightened awareness allows your colleagues to develop their own sense of the need for improvement, especially when they understand the link between communication failures and poor patient safety and quality of care.

Action Step 2.5: Proactively identify and address potential dangers for your LEP patients. Engage clinical leaders by bringing attention to the potential negative health implications of poor communication. Communication failures between patients and their health care providers have been associated with adverse events and poor quality health care, such as medication or medical errors, which in turn has been associated with severe clinical consequences, even death (Cohen, Rivara, Marcus, McPhillips, & Davis, 2005; Divi, Koss, Schmaltz, & Loeb, 2007; Mitka, 2007). While it is widely acknowledged that communication barriers increase the risk of adverse events and poor quality of care for LEP patients, many providers and administrators fail to recognize the danger under their own roof. Reporting the level of risk within your own organization will make the issue a reality and help mobilize support for needed improvements. Work with your organization’s quality assessment and safety programs to obtain estimates on the scope of errors and adverse events due to poor communication. In many cases, only anecdotal evidence of communication failures will be available, but even a few well-documented instances of language-related difficulties will help others start thinking more locally (and more seriously) about this global problem.