This presentation reviews the challenges faced by foreigners seeking health care in Japan, summarizes key points from a national survey, and analyzes how the US CLAS standards could offer a framework for addressing cultural and linguistic needs in Japan. Presentation to the Japan Academy of Nursing Evaluation, Tokyo, March 15, 2015.

1. Improving health care for foreigners in Japan:
Stories, Data and Policy Models
Julia Puebla Fortier, Director, DiversityRx

2. Julia Puebla Fortier
Executive Director
DiversityRx – Resources for Cross Cultural Health Care
www.diversityRx.org

3. DiversityRx:
Improving health care for a diverse world
 Policy development
 Research
 Information dissemination
 Education and training
Working with:
 Hospitals and health
departments
 Universities
 Philanthropic foundations
 Government agencies
 International organizations

4. Medical tourists
Foreign brides
International students
Expat professionals
Migrants Indigenous people
Foreign workers
Refugees
Minorities

5. Diversity in Japan
 The number of foreign residents has more
than doubled since the 1990s:
 China 647,230
South Korea/DPRK 526,575
Philippines 206,769
Brazil 185,644
Vietnam 61,920
U.S.A.49,216
Peru 48,976
Thailand 40,699
Taiwan 29,466
Nepal 27,584
Indonesia 26,171

6. Japan’s future diversity
 Increase Japan’s participation in global marketplace
 Prepare Japan for influx of foreign visitors for 2020 Olympics
 Government goal to double number of tourists to 20 million
 Build medical tourism industry
 Goal to increase to 30 million by 2030 the number of visitors coming to
Japan for medical treatment.
 Expand international participation in Japanese university
education
 In 2012, there were more than 137,000 foreign students and the current
government aims to double these numbers by 2020.
Economic and Political Initiatives

7. Getting health
care in Japan

8. Emergency Room visit:
Foreign patient perspective
 Big red sign at entrance, Japanese only – Emergency Room?
 Reception desk – many signs, nothing in English
 Intake form in Japanese with English translation
 iPhone and Google Translate to talk to receptionist
 Nurse triage – no English. Called friend on phone
 Doctor and x-ray technician speak English
 Discharge forms in Japanese, another doctor to translate
 Translated map on the way out

9. The impact of language
barriers on patient
behavior

10. How the patient feels
 Disempowered, frustrated
 Overwhelmed by everyday life -- don’t want to take on the health
system too
 Fear interactions I don’t understand, from the first phone call to
the actual visit
 Can’t think clearly in the moment, don’t ask questions
 Don’t want to bother anyone -- just try to be polite and deferential
 Grateful for anything that makes sense

11. How the patient acts
 Doesn't do routine care
 Doesn't do follow-up tests
 Puts off going to the doctor until it can’t be avoided
 Doesn’t know how to find a good doctor
 Goes to a doctor just because they speak my language
 Not assertive, doesn’t try to discuss options
 When they get poor care, don’t report it - just don’t go back

12. Stories are nice
but data affects policy
and social change

13. National survey of foreign patients
1. To analyze the experience of foreign residents and visitors about
 their experience accessing health care
 interactions with health care providers and staff
 any cultural or linguistic barriers to effective communication and
delivery of health care services.
2. To identify opportunities and challenges to improving the health
care experience of foreigners in Japan.
Purpose

14. Survey methods
 Pretest development and testing in Kobe (Spring 2014)
 National online survey (October – December 2014)
 Survey:
 Survey language: English. Future languages dependent on financial and
technical resources
 39 substantive questions
 8 demographic questions
 Request for interview

15. Survey target audience
 Foreign-born residents
 Expatriate (short-term) professionals and their families
 Short-term/migrant workers
 International students and educators
 Medical tourists

16. Sample questions
 Did you use an interpreter during
this visit to talk to the medical
provider or staff?
 If an interpreter was not
provided by the office or
hospital, did you bring someone
else to interpret for you when
you talked to the provider?
 If you did not have an interpreter
but you needed one, do you think
this negatively affected the
quality of care you received?
 Did the provider give you an easy
to understand explanation
about your condition and the next
steps for your treatment?
 If a prescription was provided, did
you understand what the
medication was, how to take it, and
any possible side effects?
 If the provider ordered additional
blood tests, x-rays, or other tests,
did she or he explain the reason?
 Did the provider answer all your
questions to your satisfaction?
Language issues Doctor-patient communication

17. Survey responses (486 total)
(Sample preliminary data, please do not quote)
 57 percent delay getting care because of language or cultural
difficulties
 74 percent prefer to communicate in English
 60 percent needed an interpreter sometimes or chose an English
speaking doctor
 80 percent of those who needed an interpreter but didn’t have
one said it may have negatively affected the quality of care
 55 percent said the doctor did not give or only gave a somewhat
clear explanation about their condition and treatment
 58 percent said their questions concerns were not completely
addressed by the doctor

18. Many stories to tell:
Qualitative responses
 High number of qualitative responses—
 239 answers to “Did any cultural issues arise during the consultation
that might have had an impact on your communication or negotiation
with the provider? Please describe.”
 259 respondents indicated a willingness to be contacted for
further phone/email interview.

19. Value of the survey to nurses
 Shows what experiences foreign patients have, and how nurses
can respond better to their needs
 Could be used to evaluate patient care experience in hospitals
 Results could be used to promote organizational changes that
better support foreign patients

20. How to improve services to
foreign patients:
The role of standards

21. Global context
 U.S. – Civil Rights Law, CLAS
Standards, state laws, Joint
Commission, NCQA, National
Quality Forum, health reform
 European Union – Migrant
Friendly Hospital demonstration
and Amsterdam declaration,
individual country policies,
Council of Europe
 Australia and New Zealand
standards
 Global – WHO Health Promoting
Hospitals Task Force, WHO Global
Consultation on Migrant Health
Laws and regulations, standards, resolutions,
performance measures, accountability frameworks

22. United States CLAS Standards
(2000, 2013)
 National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
The National CLAS Standards are designed to
advance health equity
improve quality
help eliminate health care disparities
by establishing a blueprint for health and health care
organizations to respond to cultural and linguistic issues that arise
in health care.

23. CLAS Standards
Principal Standard
 1. Provide effective, equitable, understandable,
respectful, and quality care and services that are
responsive to diverse cultural health beliefs and
practices, preferred languages, health literacy, and
other communication needs

24. CLAS Standards: Theme 1
Governance, Leadership, and Workforce
 2. Promote and sustain governance and leadership
that promotes CLAS and health equity
 3. Recruit, promote, and support a diverse
governance, leadership, and workforce
 4. Educate and train governance, leadership, and
workforce in CLAS

25. CLAS Standards: Theme 2
Communication and Language Assistance
 5. Offer communication and language assistance at
no cost
 6. Inform patients of the availability of language
assistance
 7. Ensure the competence of people providing
language assistance
 8. Provide easy to understand information and
signage

26. CLAS Standards: Theme 3
 Engagement, Continuous Improvement, and
Accountability
 9. Infuse CLAS goals, policies, and management
accountability throughout the organization’s
planning and operations
 10. Conduct organizational assessments of CLAS
activities
 11. Collect and maintain demographic data

27. CLAS Standards: Theme 3
 Engagement, Continuous Improvement, and
Accountability
 12. Conduct assessments of community health assets and
needs
 13. Partner with the community to plan and implement
services for diverse populations
 14. Create conflict and grievance resolution processes that
address cultural and linguistic issues
 15. Communicate the organization’s progress in
implementing and sustaining CLAS

28. Reasons to adopt standards
 Respond to demographic changes.
 Highlight the special needs of foreign populations
 Improve the quality of services and primary care
outcomes.
 Benefit from a clear organizational framework
 Gain a competitive edge in the market place.
 Decrease the likelihood of liability/malpractice claims.

29. Keys to success
 Top leadership support
 Educating all staff
 Financial resources
 Incorporate into other strategies (quality
improvement, patient safety, improving outcomes)
 Show successful models
 Step by step approach

30. The need for advocacy and
education

31. Advocating culturally and linguistically
responsive services in the United States: Who
 Representatives of foreign/non-English speaking populations
 Medical interpreters
 Health care providers that care for foreign populations
 Policymakers (politicians and health department staff)
 Researchers
 Foundations
 Journals

32. Advocating culturally and linguistically
responsive services in the United States: How
 Human right of equal access to health care
 Impact of language/cultural barriers on health care
delivery
 Legal and financial consequences of medical errors
 Good practice and policy models
 Improve quality of care
 Reduce health disparities

33. Advocating for culturally and linguistically
responsive care in Japan: health organizations
 Educate all working health care staff
 Change hospital policy and practices
 Hire bilingual staff, patient advocates
 Train professional and volunteer interpreters
 Use telephone interpretation services

34. Advocating for culturally and linguistically
responsive care in Japan: policymakers
 Human rights
 Quality of care
 Reduce medical errors
 Attract foreign patients through medical tourism

35. Leadership from nursing
administrators and educators
 Educate working nurses and future nurses about the needs of
foreign patients, cross cultural health care, and how to work with
interpreters
 Encourage second-language study by Japanese nurses, and
support the integration of foreign nurses
 Promote evaluations of foreign patient care experiences in health
care organizations
 Promote culturally and linguistically responsive care at the
administrative level as a patient safety and clinical efficiency issue
 Develop nursing practice guidelines for working with foreign
patients

36. Raise awareness
 Document good practices
 Speak at health care conferences
 Conduct research and publish journal articles
 Write about what goes wrong in newspaper and
magazine articles

37. Nurses are the most important
advocates for patients and their
families. Your sensitivity and
concern for quality care can
benefit all patients, where ever
they come from.

38. ご静聴ありがとうございました

39. For more information:
Foreign patient survey:
www.diversityRx.org/health-care-Japan
CLAS standards and blueprint:
http://1.usa.gov/1hS8SAv
Transcultural Nursing Society practice
standards:
http://bit.ly/1ansoFM
Contact:
(English) Julia Puebla Fortier, rcchc@aol
(Japanese) Rie Ogasawara, ogaoga616@yahoo.co.jp