Crosswalk: National CLAS Standards and TJC Hospital Accreditation Requirements
This crosswalk compares the Office of Minority Health’s National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care to The Joint Commission’s 2015 Standards for the Hospital Accreditation Program. Each of the 15 National CLAS Standards is presented alongside the applicable Joint Commission standards. There is not a one-to-one correlation between the National CLAS Standards and Joint Commission standards, as several of the Joint Commission’s requirements overlap with the overall intent and objective of each National CLAS Standard.
Patient-Centered Communication Standards for Hospitals
The patient-centered communication standards were developed as part of a larger initiative to advance the issues of effective communication, cultural competence, and patient- and family-centered care. The patient-centered communication standards for hospitals were fully implemented in July 2012 and are published in the Comprehensive Accreditation Manual for Hospitals (CAMH). The standards address issues such as qualifications for language interpreters and translators, identifying and addressing patient communication needs, collecting patient race and ethnicity data, patient access to a support individual, and non-discrimination in care. Additional guidance on implementing the patient-centered communication standards is provided in the Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals monograph (see below). Clarifications on the expectations for collecting patient race, ethnicity, and preferred language data are provided in Standards Frequently Asked Question (FAQ) documents on this website.
Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals
This monograph was developed by The Joint Commission to inspire hospitals to integrate concepts from the communication, cultural competence, and patient- and family-centered care fields into their organizations. The Roadmap for Hospitals provides recommendations to help hospitals address unique patient needs, meet the patient-centered communication standards, and comply with related Joint Commission requirements. Example practices, information on laws and regulations, and links to supplemental information, model policies, and educational tools are also included. The patient-centered communication standards are presented in Appendix C, which provides self-assessment guidelines and example practices for each standard.
- Links to Joint Commission projects and reports have been updated throughout the document.
- Additional resources have been included in Appendix E.
- Appendix C has been revised to update the standards language. Although the requirements have not changed, the previous references indicating that the standards would not affect the accreditation decision have been deleted.
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide
This field guide from The Joint Commission urges U.S. hospitals to create a more welcoming, safe and inclusive environment that contributes to improved health care quality for lesbian, gay, bisexual, and transgender (LGBT) patients and their families. The Field Guide features a compilation of strategies, practice examples, resources, and testimonials designed to help hospitals in their efforts to improve communication and provide more patient-centered care to their LGBT patients. This monograph was developed with support from the California Endowment.
Video: Promoting Health Equity and Patient-Centered Care
This brief video (less than 10 minutes) contains a discussion and slide presentation of the Joint Commission standards and other resources available to promote health equity and patient centered care. The video features staff from the Joint Commission’s Division of Healthcare Quality Evaluation discussing the standards and highlighting two educational monographs that go above and beyond what is required in the standards to assist hospitals and health care organizations in their efforts to advance the concepts of effective communication, cultural competence, and patient- and family-centered care.
Additional Reports and Resources
Attributes of a Health Literate Organization
Published by the Institute of Medicine’s Roundtable on Health Literacy, with involvement from the Joint Commission’s Dr. Paul Schyve, this paper describes 10 attributes of a health literate organization. These are guidelines that can be used by providers and small groups/teams that deliver health care, health care organizations that house providers and groups/teams that deliver health care, and payors and health plans.
R3 Report Issue 1
Published for Joint Commission accredited organizations and interested health care professionals, R3 Report provides the rationale and references that The Joint Commission employs in the development of new requirements. While the standards manuals also provide a rationale, the rationale provided in R3 Report goes into more depth. The references provide the evidence that supports the requirement. R3 Report may be reproduced only in its entirety and credited to The Joint Commission. Issue 1 of the R3 Report, published in February 2011, is focused on the patient-centered communication standards.
Video: Improving Patient-Provider Communication
The Joint Commission and the U.S. Department of Health & Human Services (HHS) Office for Civil Rights have worked together to support language access in health care organizations with the video Improving Patient-Provider Communication: Joint Commission Standards and Federal Laws.
Amid growing concerns about racial, ethnic and language disparities in health care, The Joint Commission and the U.S. Department of Health & Human Services (HHS) Office for Civil Rights have worked together to support language access in health care organizations with the video Improving Patient-Provider Communication: Joint Commission Standards and Federal Laws.
Health care organizations face challenges to accommodate increasingly diverse patient populations – more than 28 million people with hearing loss and about 47 million people who speak a language other than English. Language access remains a matter of national importance. Effective communication is a critical aspect of safe, quality patient care. Many patients of varying circumstances require alternative communication methods, and this new video will help health care organizations to determine the best methods of care for meeting these communication needs.
The video highlights what is required by Joint Commission standards as well as Federal civil rights laws with respect to patients who are deaf/hard of hearing or limited English proficient. Accompanying the video is a list of resources and tools that health care organizations can use to build effective language access programs.
View video (Part 1 - Part 4)
Download the list of resources: Resources Related to Effective Communication
For additional information on federal laws related to language access and for additional resources on effective communication, please visit the Office for Civil Rights Web site. Language Access and the Law is a document prepared by the HLC staff that summarizes the current laws and regulations that address the provision of language services.
Exploring Cultural and Linguistic Services in the Nation's Hospitals: A Report of Findings
The first report released by the HLC study presents the challenges hospitals face when providing care and services to culturally and linguistically diverse populations, and discusses the way hospitals are addressing those challenges. For more information, read a 1-page summary of the Report of Findings.
Access a free copy of the Report of Findings (Requires Adobe Reader).
One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations
Our latest research report provides a framework for hospitals and other health care organizations to develop and employ practices for meeting diverse patient needs. The report also includes a self-assessment tool that organizations can use to initiate discussions about the needs, resources, and goals for providing the highest quality care to every patient served. For more information, read a
1-page summary of One Size Does Not Fit All.
Access a free copy of the One Size Does Not Fit All report (Requires Adobe Reader).
"What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety."
This public policy white paper frames the existing communications gap between patients and caregivers as a series of challenges involving literacy, language, and culture, and suggests multiple steps that need to be taken to narrow or even close this gap. The detailed solutions developed by a special Joint Commission Expert Roundtable focus on making effective communications a priority in protecting the safety of patients; addressing patient communications needs across the spectrum of care; and pursuing public policy changes that promote better communications between health care practitioners and patients.
Access a free copy of "What Did the Doctor Say?" (Requires Adobe Reader).