Outside Jerusalem

On May 21 we finished the first professional development seminar for 17 cultural competency coordinators in Israeli health care organizations. They came from hospitals such as Hadassah, Shiba-Tel Hashomer, Sourasky Medical Center, Rambam, and more. For some this was their first step in the cultural competency process of their respective organizations. The seminar included 5 meetings and a webinar with cultural competency coordinators from the US and Canada. For a link to the post on the opening of the seminar click here.

From the third meeting: panel of hospital directors – from Sheba, Alyn and Bikkur Holim – and the role of management in cultural competence

The Tour of Cultural Competency in Action The fourth meeting was an all-day tour of cultural competency in action in Jerusalem. The first stop was at the Alyn Rehabilitative Hospital, which began its cultural competency process in 2007. Mrs. Naomi Geffen gave us a tour of the different departments and clinics, explaining the main issues, such as translation in medical and educational settings, ensuring patient and caregiver are the same sex in some cases, dress code, separation of boys and girls in the therapeutic pool, adapting the rehabilitation process to the patient’s culture, and more. Participants also visited the Muslim prayer room that was established in cooperation with the JICC and community members two years ago. We also received examples of materials and documents that had undergone linguistic and cultural adaptations, from a therapy schedule in the patient’s language, the internet site, release letters, and more. We were all amazed at what was accomplished here – today, hospital staff speak in a new language, one that is more advanced and without stereotypes. The second station on the tour was a well-baby clinic that provides services for the Ultra-Orthodox Jewish (Haredi) population in Meah Shearim. We met the clinic’s manager and a leader from the Toldot Aharon community, which is considered to be one of the more conservative and separatist divisions of ultra-orthodox Judaism. The clinic and its services have undergone a process of adaptation to the needs and approaches of the Haredi population, facilitated by the JICC, which included adaptation of the physical environment (pictures, brochures in Yiddish), training for nurses about how to appropriately approach mothers, and more. We intervened, with the full cooperation of a leader in the Haredi community, after a serious epidemic of whooping cough and measles in the Haredi community that spread because of a low rate of immunizations. We discussed with them a number of issues including: vaccinations and immunizations, developmental delays, and more. We also heard about a unique project for first-time mothers, and the special adaptations that had been made for the Haredi community. The third stop was Hadassah – Mount Scopus. Ms. Gila Segev gave an overview of the project that began in April 2010, just as she was appointed cultural competency coordinator. Gila recruited volunteers who were trained in verbal translation/ interpretation by the JICC and lecturers from the Department of Translation and Interpreting Studies at Bar Ilan University. Because 60% of the hospital’s patients are Arabic speakers it was decided to concentrate on Arabic. We also heard a first-hand account of the Hebrew – Arabic translating / interpreting process from a volunteer. The visit concluded with a panel of representatives of different communities to learn about the needs of patients and how to work with the different communities successfully over the long term. The panel included: Dr. Itchik Seffefe Ayecheh (from the Tene Briut organization that advances the health of Ethiopians in Israel), who felt that the focus should be on training and workshops for the medical staff to understand the importance of the relationship with the communities. Dr. Meir Antopolski (“Meeting Point” organization whose goal is to create a new cultural space for the Russian sector) who believes that the linguistic dimension is a critical obstacle in the relationship with the communities, and Mr. Fuad Abu-Hamed (who operates Clalit Health Services clinics in East Jerusalem) gave a fascinating overview of the Palestinian communities of East Jerusalem.

The panel with the Russian, Ethiopian and Palestinian community representatives

Webinar The webinar was on May 16, focusing on the experience of 3 cultural competency coordinators from abroad. Some of the speakers are full-time cultural competency workers with staffs dedicated to responding to the multicultural needs of patients, from special menus and food preparations to organizing different cultures’ holiday celebrations and commemorations. All speakers presented a model that many of the participants could strive toward. The speakers included:

• Virginia Tong, Vice Presidents of Cultural Competence, Lutheran Medical Center, New York
• Young Lee, Director of Training and Development, Coney Island Hospital, New York
• Branka Agic, PhD., Manager, Health Equity Center for Addiction and Mental Health (CAMH), Toronto, Canada

A snapshot from the world cultural competence coordinators webinar

Summing Up The fifth meeting featured a discussion about socio-political tensions that affect the patient-caregiver relationship and how the caregiver and the cultural competency coordinator can relate to it on an organizational level. One example was of ongoing discussions amongst the staff on social-political tensions, with an understanding that these tensions are not limited to the patient-caregiver relationship, they are also found between staff members, which also requires special attention. Later on, Dr. Anat Jaffe from the Hillel Yaffe Hospital in Hadera, and one of the founders of Tene Briut, spoke to us. Dr. Jaffe surveyed the medical meeting point from an inter-cultural perspective. In her lecture she focused on her dealings with the Ethiopian community and diabetes, from her expansive experience as a doctor in the community and in the hospital. The final meeting also included presentations of the pilot initiatives that participants worked on during the seminar. For example, representatives from the Western Galilee Hospital in Nahariya created and passed around a mapping and evaluation survey of different cultural and linguistic aspects of their patients. The representative of Bikkur Holim Hospital in Jerusalem is making the hospital’s voicemail system accessible in 4 languages, and the representative of the Italian Hospital in Nazareth changed the internal signage in the departments to 3 languages. Ms. Avigail Kormes from the New Israel Fund closed the course with warm remarks and wished them success.

For an article in Hebrew in Ha’aretz newspaper by Dan Even 4 June 2012 click here.

A translation from Ha’aretz article :

The Era of Multiculturalism Reaches Israeli Hospitals

The hanging of pictures on the wall of non-blonde children, the creation of prayer rooms, and the translation of discharge papers into French – these are the new practices in hospitals of a new policy that requires cultural competency. In February 2013 a new Ministry of Health directive goes into effect requiring cultural competency in Israel medical institutions. As part of the directive, each institution is required to appoint one member of management to be in charge of cultural competency, who will be responsible to implement the new practices. Initial training sessions for coordinators in the past month reveal that the process does not include merely cosmetic changes, such as posting direction signs in Arabic, but seeks to change the atmosphere in the entire hospital to make it accessible to the multiple cultures in the state, especially during a period in which the social fabric of the country creates endless difficulties. One of the organizations that began training cultural competency coordinators is the Jerusalem Intercultural Centre (JICC), that has been advancing this topic in the capital’s hospitals since 2007, with the support of the Jerusalem Foundation and the New Israel Fund. This month the JICC held a course training for for 17 cultural competency coordinators from 14 hospitals at the Schoenbrun School of Nursing, Tel Aviv Sourasky (Ichilov) Medical Center. According to Dr. Hagai Agmon-Snir, the director of the JICC, “cultural competency is more than signage and the translation of forms. Patients need to receive all the medical services of the facility in a way that is accessible both linguistically and culturally, whether that means adding foreign language newspapers to the waiting rooms or making the pictures on the department walls more culturally applicable. When the pictures on the walls only portray blonde Dutch children, it’s most problematic, and its important to include pictures of children from diverse backgrounds, so that people will feel as much a part of the place as possible.” One of the issues that the JICC seeks to integrate in this new process is accessibility of diverse religious and cultural services in the medical facilities. “Opening prayer rooms for different religions is not a political matter, but a professional one,” says Agmon-Snir. Muslim prayer rooms currently operate in only a few hospitals in the country, including Rambam, Alyn, and Hillel Yaffe. “In every self-respecting hospital in the West it’s customary to address diverse religious needs. It appears that addressing religious needs favorably influences the medical treatment, and it is important to advance this in Israel as well,” says Agmon-Snir. Cultural competency also includes the correct usage of terminology that is sensitive to different cultures. Especially now, when social tensions are at their peak, whether related to the ultra-Orthodox, foreign workers or African immigrants, it is incumbent on medical staff to exercise more sensitivity. “It’s important to know the appropriate terminology for each culture. When dealing with the Haredi population, modesty in speech is required. In the ultra-Orthodox community, for example, it’s not customary to says ‘kaki’ or ‘excrement.’ One also has to know how to relate to rabbinic opinions which may influence the type of treatment, just as one has to adapt to secular patients who come to the doctor with information they have gotten on the internet.” Sensitivity to concepts is also required for immigrant workers. “In our training we teach how to be sensitive to every culture, even to the foreign patient from Eritrea,’ says Agmon-Snir. “In some cultures, for example, ‘no’ is not a firm refusal, but rather a request to hear more information before making a decision. In some cultures, when a patient bows his head he is showing respect for the caregiver, and it is not at all a refusal of care.” Another course for coordinators responsible for cultural competency coordinators from 24 hospitals began this month, under the auspices of the Ministry of Health, via Dortal Consulting. According to Dr. Emma Auerbuch, coordinator for reducing gaps in health care for the Ministry of Health, “Our approach is a little different. For example, anything related to places of worship, in our opinion, is the decision of the administrator of the medical facility, and should not to be imposed from above. In all matters related to cultural accessibility, one must remember that it is the goal of health facilities to provide medical treatment, and we try as much as possible to avoid tension.”

The different approach between the bodies can also be found with regards to the translation of patients’ forms. The JICC seeks to translate all the forms a patient might receive, including discharge papers, into various languages.. Auerbuch stresses that “the directive requires translation only of forms that require a patient’s signature, but we won’t prevent a hospital from offering translations of other forms as well. Recently a health fund in Netanya began offering medical information in French, since there is a large concentration of French speaking immigrants there. We can only congratulate them for that.” The courses include among other things training in preventing social tensions during the medical treatment. “This is an especially relevant topic in Israel, because people here tend to cross the lines between professional and political. Many times a patient will tell a doctor or a nurse what he thinks, for example, ‘you’re Russian and that’s why you act that way.’ The intercultural contact creates a challenging dynamic, including the use of stereotypes, and medical staff must learn how to maintain professional interaction, as much as possible,” says Agmon-Snir. “One must remember that the patient’s welfare is paramount, and the role of the health system is not to educate the patients. It’s not the doctor or nurse’s job to teach the patient manners or how to behave. A nurse may certainly put a disrespectful patient in his place, but in a professional context. Saying to a patient, ‘you Ethiopians are always late’ is not appropriate. Special attention is being given to emergency rooms. According to Dr. Agmon-Snir, “Although the pressure in the emergency room complicates the ability to give a patient detailed explanations, sometimes investing three extra minutes in explanations can save confusion and much time later on.”

We’ve taken yet another step in becoming one of the national leaders and reference points of Cultural Competency in the health care system in Israel. On Monday, 23 April we held the first meeting of a professional development seminar cultural competency coordinators from around the country. This is the first such seminar ever to take place in Israel! Our 16 participants included representatives from the major hospitals in the country: Hadassah Medical Center and Sha’are Zedek in Jerusalem; Shiba-Tel Hashomer and Sourasky Medical Center in the Tel Aviv area, Rambam in Haifa, and more.

We have been working to advance cultural competency in the health care system in Israel since 2007, and we are in constant contact with most of the cultural competency coordinators around the country. Most of these coordinators have been appointed since the publication of the Ministry of Health’s Cultural Competency Directive, published in February 2011, that will require medical interpretation services, education and training of medical staffs, environmental adaptations of all health care institutions by 2013. As a first step, the Directive requires health care organizations to appoint a cultural competency coordinator to be responsible for all the processes that work toward equal cultural and linguistic accessibility for all.

Our unique seminar is taking place in cooperation with the Ministry of Health and is a natural continuation of the Directive. The training will provide knowledge and tools to enable cultural competency coordinators to assimilate the Directive in their institutions. It is important to note that most cultural competency coordinators are already in senior management positions in their organizations.

The 5-day training seminar, which will meet weekly until the end of May, will include 50 hours of frontal lectures as well as a webinar with cultural competency coordinators from Canada and the USA. Our funders for this course are the Jerusalem Foundation and the New Israel Fund. The course is being held at the Nursing School at the Tel Aviv Sourasky Medical Center.

The training course will cover:

• Introduction to Cultural Competency: Medical interpreting and translation and mediation in health services, models of intercultural communication between patient and caregiver, cultural dimensions in interpersonal communication, dealing with political and social tensions, different cultures’ approaches to health and sickness, and more.
• Practical guidance for cultural competency processes in health care organizations – from the cultural competency coordinator’s first steps to full organizational adaptation.

It will also include guest lectures on the following subjects:

• Inequality in the health care system and the role of the cultural competency coordinator in reducing gaps.
• Acquaintance with the main theories of cultural competency in Israel and around the world.
• Tools for implementing principles of cultural competency in a health care organization.
• Tours of hospitals and clinics that are undergoing cultural competency processes.
• Clinical aspects of different cultural approaches to sickness and health.
• Culturally-dictated social norms.
• Cultural competency from the viewpoint of health organization administration.
• Cultural competency from the viewpoint of social organizations dealing with community health.

The opening lecture was given by Dr. Emma Averbuch from the Unit of Decreasing Health Inequality at the Division of Health Economics and Insurance Division of the Israeli Ministry of Health. Dr. Averbuch emphasized the importance of the cultural competency coordinator and how he or she can contribute to decreasing inequality in health care. She also surveyed the Ministry’s activities thus far in advancing cultural competency and decreasing inequality in the system.

Prof. Leon Epstein speaks on Inequality in Health at the Cultural Competence Coordinators training

The participants also had the first session covering the “Guide for Cultural Competency Processes in Health Care Organizations”, which is a practical guide we developed over the past 2 years. It details the steps that must be taken to assimilate cultural competency principles in an organization. This meeting concentrated on defining the role of the cultural competency coordinator, as well as first steps in creating a suitable buzz within an organization for cultural competency. In addition, the participants related their experiences with the community, and the discussion that followed focused on the need to establish and expand these relationships to be helpful in times of crisis.

Part of the training included a practical exercise in creating change. Each participant was asked to choose a small initiative that is related to at least one component of cultural competency that he or she wanted to change by the end of the training course at the end of May. This initiative needed to be something easily implementable and with high visibility in the organization. Participants chose projects such as mapping needs and resources, linguistic accessibility of restrooms, and more.

Simulation of a case of cultural competence at the training

Two guest lectures dealt with the relationship between risk management and cultural competency, from Ronen Regev-Kabir, Deputy Director, Public Trust organization, and Netalie Goldfarb, the Care Competency Unit of the Ministry of Health. Our own Dr. Hagai Agmon-Snir closed the day with a workshop on cultural dimensions and the main values of interpersonal communication, to give a taste of the cultural competency workshop that will be the focus of the second workshop on 30 April.

In parallel to this meeting, an Internet discussion group was established that will deal with cultural competency in the health care system in Israel. There will be participants from within and without the health care system and it will enable participants to share knowledge in this area. You can view the discussion group and the course’s accompanying materials here.