Questions & Answers

FREQUENCY OF ASKING ABOUT RACE, ETHNICITY, AND LANGUAGE

Do we need to ask [race, ethnicity, and language] for each visit if it was given by patient at first visit?

Response: Patients do not need to be asked their race, ethnicity, and language every time they visit the hospital. However, hospitals should have a system to ask patients every six months or year, as this information may change over time. Hospitals also need to ask patients this information after the first visit if the patient was not able to answer these questions when they first visited the hospital (i.e. they were unconscious, etc).

Comments from Hospitals: Some hospitals are finding that patients whose fields are completed in totality in the last 30 days often do NOT recall being asked. This suggests that staff may be making visual assumptions.

PAPER-BASED VS. VERBALLY ADMINISTERED QUESTIONS

Should questions on patient race, ethnicity, and language be asked verbally or with the help of a form?

Response: Questions can be asked either verbally or through a paper form, as hospitals vary in how and when these questions are asked of patients.

DATA COLLECTION AND STAFF BURDEN

How much extra time does collecting these data add to the admission process? How do you justify this collection of more in depth race/ethnicity/language data to an admissions staff that is already very busy?

Response: Research conducted by Dr. Romana Hasnain-Wynia and colleagues found that asking patients questions on race, granular ethnicity, and language took an average of 37 to 48 seconds. This should not pose a heavy burden to hospital admission and registration staff. The findings of this study were published in the American Journal of Public Health: http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2005.062620.

ADDRESSING STAFF RELUCTANCE TO ASK QUESTIONS

Many registration staff, who have grown up in this area, "assume" the race/ethnicity and language spoken, rather than asking the patient. They are actually embarrassed to ask patients these questions.

Response: Staff training is critical to ease discomfort regarding asking patients questions about their race, ethnicity, and language. When admissions/registration staff understand why these data are collected and why patients need to self-report this information, staff discomfort is minimized.

Comments from Hospitals: The difficulty that hospital staff encounter is not explaining why patient data is collected, but how to address pushback from patients and how to ease patient discomfort. Some staff members feel competent to ask patients these questions, BUT DO NOT feel it is their job to collect these types of information. Ideally, they indicate this should be a provider function so it facilitates a discussion.

A key issue is that staff are simultaneously asking these questions in the practice setting and caring for the patient. It takes extra time and patients are more concerned about having their care needs addressed. Some hospitals are considering a hybrid method.

RACE VS. ETHNICITY

Why is "Hispanic/Latino" not considered a race?

Response: OMB defines "race" as the five broad continental racial categories — White/Caucasian, Black/African American, American Indian/Alaskan Native, Asian, and Native Hawaiian and Other Pacific Islander. Hispanics and Latinos may have origins in one or more of these racial categories. Often times, Hispanics and Latinos do not see themselves reflected in the racial categories and respond by indicating "Other" or by stating that they already responding the question (by answering the ethnicity question).

What is the difference between race and ethnicity? What does a Caucasian with Hispanic grandparents report?

Response: Race is defined by OMB as the five broad continental races. In 2009, the IOM Report on the Standardized Collection of Race/Ethnicity Data for Healthcare Quality Improvement defined "ethnicity" as ancestry, distinguishing it from country of origin.

Per OMB's definitions of race and ethnicity, a Caucasian person with Hispanic grandparents could answer "yes" to the Hispanic ethnicity question and "White" to the race question. However, their answer would depend on how they perceive themselves.

NEW OSHPD CODES FOR LANGUAGES

We have a large Assyrian population in our community are you aware if OSHPD will be eventually adding this to the language codes?

Response: We do not think OSHPD will be making changes to their coding procedures in the near future. Currently, OSHPD has 3-character codes for some languages. For languages for which a code is not available, there is the option of writing in languages in a 24-character free text space.

Other hospitals have created granular lists that are part of their data standards and have procedures to collapse these responses into categories set by OSHPD, OMB, and the State.

MULTIPLE RACE RESPONSES AND IDENTIFYING HEALTHCARE DISPARITIES

What do you do when someone identifies with multiple selections?

Response: Patients who identify as multiple race are reported as "Other" to OSHPD. Question #3 on the sample patient demographic questionnaire asks patients who indicate more than one race whether they identify with one race in particular.

Comments from Hospitals: Identifying disparities becomes complicated when patients self-report multiple racial categories. The reality is we have an increasingly blended society where patients identify with more than one ethnicity, language, etc. This makes accurate reporting and identifying health disparities significant challenges. The data are there, but they need to be pulled together in order to make an accurate assessment of existing disparities.

ADDRESSING "MEXICAN" AS A RESPONSE

What should the response be if a patient states that they are "Mexican"?

Response: Hispanic origin or descent should not to be confused with race. A person of Hispanic origin may be of any race. Patients who have indicated Hispanic or Mexican ethnicity should be provided the options for selecting a race.

If a patient states that their ethnicity is "Mexican", their response should be rolled up into the "Latino" ethnicity category. If a patient states "Mexican" as their race, it should be reported as "Other" to OSHPD.

OBSERVATION VS. SELF-REPORTED RACE, ETHNICITY, AND LANGUAGE

If a patient states one race, but they obviously look like another, how do you handle that?

Response: Self-reported information trumps what would be reported by observation. We have to respect information that is self-reported by patients, regardless of what it observed by staff.

If a patient refuses to disclose their race, are hospital staff prohibited from entering a race based on observation?

Response: Hospital staff should not record a patient's race based on observation, and should not push the issue with patients who do not wish to answer this question. If a patient refuses to disclose their race, the "Declined" or "Patient Refuses to Answer" choices should be marked. These patients should be reported as "Unknown" to OSHPD.

If the patient is speaking to hospital staff, and is able to hold a perfect conversation in English, should we simply put English for the language, or should we always ask the patient? Is it important to find that a patient's primary language is Spanish, for example, even though they can hold a conversation in English?

Response: The gold standard is self-report. Hospital staff should ask the patient what language they feel most comfortable in speaking with a doctor or nurse, instead of relying on observation. Some patients who are bilingual may still want to communicate in a language other than English. Some hospitals may choose to also ask what language patients feel most comfortable in receiving written medical information, as some people can speak, but not read English well.

"OTHER" VS. "UNKNOWN"

What is the difference between "other" and "unknown" race and ethnicity?

Response: The "Other" category is reserved for:

• Any possible options not covered in the categories provided in the sample race and ethnicity questions.
• Patients who cite more than one race and primary race cannot be determined.

"Unknown" is limited to two scenarios:

• This category includes patients who cannot or refuse to declare race.
• If the patient's race is not recorded in the patient's medical record, the patient's race should be reported as Unknown.

TRANSLATION OF TOOLS

Will the tools be translated into other languages?

Response: Currently, there are no plans to translate the tools. Translation is an involved process, but it is a possibility in the future.

AVAILABILITY OF TOOLS

Will the tools be available after the webinar?

Response: Yes, the tools will be emailed to everyone after the webinar and the final versions will be available on the OSHPD website. We will also post the tools on a website hosted by UCLA.

SUTTER HEALTH REAL TOOLKIT

Response: The toolkit is no longer available for download.