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Policy Innovation Profile

Inclusive Policies, Communication Protocols and Ongoing Training Lead to Culturally Competent Care for Lesbian, Gay, Bisexual, and Transgender Patients


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Summary

The University of California at San Francisco Lesbian, Gay, Bisexual, and Transgender Resource Center developed a comprehensive set of policies, protocols and strategies to offer more equitable, culturally competent care to lesbian, gay, bisexual, and transgender patients at the medical center. These included altering registration forms, visitation policies, electronic systems, and verbal communication protocols to make them more inclusive and welcoming. The center also provides targeted and ongoing training to help faculty and staff implement these changes into their daily workflow and generally provide more culturally competent care. The program has enabled the medical center to achieve perfect scores on the Healthcare Equality Index since its inception (making the medical center the only institution in the country to do so); enhanced provider knowledge, skills, and confidence in addressing lesbian, gay, bisexual, and transgender issues; and made patients feel more welcome and safe.

Evidence Rating (What is this?)

Suggestive: The evidence consists of scores from the Healthcare Equality Index from 2007 onward, along with post-implementation reports from staff and patients.
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Developing Organizations

University of California, San Francisco; University of California, San Francisco Center for LGBT Health and Equity
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Date First Implemented

2005
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Patient Population

Vulnerable Populations > Lesbian/gay/bisexual/transgenderend pp

Problem Addressed

Lesbian, gay, bisexual, and transgender (LGBT) persons often experience challenges in attempting to secure culturally competent health care. With appropriate policies, protocols and training, medical systems and individual health care providers can do much to overcome both institutional and interpersonal barriers to care, but few protocols and training opportunities are available to most medical professionals on these issues.
  • Care denials and delays: Significant percentages of LGBT patients report that they have been denied care and/or fear that care will be denied to them because of their sexual orientation or gender identity.1 LGBT patients are also significantly more likely than other patients to delay needed health care because of concern about discrimination in care.2 These denials and delays result in missed opportunities for preventive interventions and the potential exacerbation of chronic conditions.3,4
  • Fear of biased care: Substantial numbers of LGBT people fear that medical providers will treat them differently because of their LGBT status.1 These patients have reported many kinds of biased treatment, including harsh and abusive language, refusals to touch or excessive precautions, and physical roughness or abuse.1Patients’ concerns about biased care may be heightened because Federal law does not prohibit discrimination against LGBT people, and neither do the majority of states.5 To help address patients’ concerns, The Joint Commission issued a requirement, effective January 1, 2011, that accredited facilities must add “sexual orientation” and “gender identity” to their nondiscrimination policies, thus assuring LGBT patients of their intention to provide unbiased care.6 In connection with this requirement, The Joint Commission has also published Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the LGBT Community: A Field Guide (http://www.jointcommission.org/lgbt/).
  • Barriers to same-sex partner visitation and support: The Joint Commission issued a requirement, effective January 1, 2011, that accredited facilities must allow same-sex partners to visit each other, and the U.S. Department of Health and Human Services has issued a rule requiring facilities participating in Medicare and Medicaid to allow same-sex partner visitation.6,7 However, despite these requirements, many same-sex partnered patients fear they will face visitation obstacles that opposite-sex partners would not encounter. They also worry that an expression of concern or affection for an ill loved one may trigger biased care, something that would not occur with an opposite-sex couple.
  • Inability to identify as LGBT: Many LGBT patients feel unseen and even unwelcome when they do not have an opportunity to inform medical providers of their LGBT status, particularly if they have a same-sex partner or coparent, or if the gender with which they currently identify is different from the one on their birth certificate. Registration and admitting procedures often do not allow them to indicate that they have a same-sex partner (instead classifying them as single), that their child has same-sex parents (instead showing one as father and one as mother), or that they identify with a gender other than the one on their birth certificate (instead showing only their birth gender).
  • Lack of protocols and provider training: Although education for health care professionals is becoming more inclusive of LGBT individuals, medical providers generally receive little or no training on how to provide culturally competent care to such patients.8 For example, most providers lack training on how to relate knowledgeably and sensitively to self-identified LGBT patients, and they do not know how to respond when patients “come out” as LGBT. Health care professionals also often lack training in routine and preventive care for LGBT patients, and relatively few are aware of the health disparities faced by this population, including elevated rates of depression, tobacco use, and alcohol abuse.2

What They Did

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Description of the Innovative Activity

The University of California at San Francisco (UCSF) LGBT Resource Center developed a comprehensive set of policies, protocols and strategies to offer more equitable, culturally competent care to LGBT patients at the medical center, including altering registration forms, visitation policies, electronic systems, and verbal communication protocols to make them more inclusive and welcoming. The medical center provides targeted and ongoing training to help faculty and staff implement these changes into their daily workflow and generally provide more culturally competent care. The center also offers patients a directory of LGBT providers. More details on key program elements follow:
  • Inclusive language in electronic systems and printed forms: The medical center modified its admitting and registration systems to be more welcoming to LGBT patients and to gather helpful information about them. For example, the electronic admitting and registration system allows patients to indicate that they are in a “registered domestic partnership.” (In California and five other states, same-sex couples who register their domestic partnership or civil union with the state receive virtually all of the rights and responsibilities conferred by marriage.) The system allows designation of “parent/guardian” instead of “mother” and “father” so that same-sex parents can readily identify themselves as such. All of these options are also available on printed medical history forms completed by patients themselves. In collaboration with the Center for Excellence in Transgender Health and the LGBT Resource Center, the UCSF Medical Center is working with the electronic medical records system to evaluate a system for how transgender patients can best identify.
  • New verbal communication protocols: The medical center developed and instituted protocols for verbal communication that demonstrate respect for and sensitivity to LGBT patients and their families. For example, the protocols suggest the following substitutions:
    • “Do you have a spouse or registered domestic partner?” instead of “Are you married?”
    • “Are you the parent or guardian?” instead of “Are you the mother or father?”
    • “Please let us know your gender,” rather than “Are you male or female?”
  • Targeted training on use of welcoming, inclusive language: Key staff participate in a targeted training program to ensure they can incorporate LGBT-inclusive systems and protocols into their daily routines, including welcoming language and sensitive responses to those patients who self-identify as LGBT. Participants include employees involved in admitting, registration, billing, and reception, as well as nurses, practice managers, and allied health professionals. The training covers LGBT-related policies and procedures and also provides background information about particular concerns of LGBT patients.
  • Ongoing cultural competency training and education: According to information provided in April 2011, approximately 850 staff and faculty, along with roughly 750 students, receive LGBT-related education and training each year through multiple programs related to LGBT concerns, including:
    • Senior leaders, legal counsel, and staff in human resources, risk management, patient relations, and spiritual care receive regular training and updates on LGBT concerns.
    • The medical center offers online information about LGBT health to all faculty and staff.
    • The health professional schools associated with the medical center incorporate LGBT health information into their curricula, and they cosponsor an annual 2-day conference on LGBT health topics for students, faculty, and staff. Trainings are offered to first- and second-year students on LGBT issues, including assigned readings, online learning modules, inperson lectures, LGBT-focused cases, LGBT standardized patients, and LGBT patient panels. 
  • Inclusive visitation policy: The medical center extends equal visitation rights to patients’ same-sex partners and to same-sex parents of patients, with these rights being documented in the medical center’s visitation policy. Information provided in July 2013 indicates that since the recent rulings related to the Defense of Marriage Act and California's Proposition 8, the entire University is in the process of reevaluating medical records and policies to reflect compliance with the Supreme Court rulings.
  • Directory of LGBT providers: The center provides an online “Out List” that lists LGBT faculty, staff, students, residents, postdoctoral researchers, and fellows. Patients can use this list to find an LGBT provider, while fellow LGBT staff can use it for informal mentoring or networking. LGBT providers as well as those providers knowledgeable about LGBT issues are encouraged to register for the Gay and Lesbian Medical Association Provider Directory.
  • Pioneering transgender care: The Child and Adolescent Gender Center (CAGC), a collaboration between UCSF and community organizations, offers comprehensive medical and psychological care, as well as advocacy and legal support, to gender non-conforming/transgender youth and adolescents. A central component of this program is UCSF CAGC Clinic, housed in the Division of Pediatric Endocrinology. Additionally, UCSF Women's Health Primary Care at Mount Zion will begin offering transgender-specific primary care health services in August 2013.

Context of the Innovation

Located in a city with the highest percentage of LGBT residents in the country, the UCSF Medical Center is one of the only health care institutions in the nation with a dedicated LGBT office. Founded in 1998, the medical center's LGBT Resource Center (previously called the Center for LGBT Health and Equity) provides programs and services designed to support equality in health, education, and employment at the medical center and nationwide. In 2004, the California legislature passed a law that took effect on January 1, 2005, which made state-registered domestic partnership the legal equivalent of marriage. A law prohibiting discrimination based on gender identity and expression also took effect in 2005. In preparation for and in response to these new laws, leaders and staff at the LGBT resource center and medical center decided to implement new policies and processes designed to incorporate more inclusive, welcoming language and practices.

Did It Work?

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Results

The program helped the medical center achieve perfect scores on the Healthcare Equality Index every year since its inception in 2007 (making the medical center the only facility in the country to do so); enhanced provider knowledge, skills, and confidence in addressing LGBT issues; and made LGBT patients feel more welcome and safe.
  • Perfect scores on equality: The medical center received a perfect score on the Healthcare Equality Index every year since the program’s inception, making it the only institution in the country to earn the top ranking in 3 consecutive years. This report rates more than 160 major health care facilities nationwide in five categories: patient nondiscrimination, competence training, hospital visitation, medical decisionmaking, and employment discrimination.
  • Enhanced provider knowledge and skills: Anecdotal reports from department heads, practice managers, and other key leaders suggest that the program has increased provider knowledge of LGBT issues and enhanced provider skills and confidence in using more inclusive language when interacting with such patients.
  • Highly satisfied patients: According to reports from the medical center's patient relations department and other medical center staff, LGBT patients feel more welcome, comfortable, and safe in disclosing personal information to providers.

Evidence Rating (What is this?)

Suggestive: The evidence consists of scores from the Healthcare Equality Index from 2007 onward, along with post-implementation reports from staff and patients.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Securing leadership support: Although the medical center’s explicit commitment to LGBT issues began in the mid-1990s, leaders still had to be convinced of the merits of creating new, more inclusive language and policies. LGBT center leaders delivered informational presentations to key hospital administrators, outlining the need for such practices and sharing stories of medical center patients whose lives and health had been negatively affected by discriminatory language and policies.
  • Forming language committee: The medical center formed an inclusive language committee, including the executive director for administration, director of patient relations, director of nursing services, director for registration and billing, and chief medical officer. The committee met regularly throughout the planning process.
  • Drafting policy: The committee worked with LGBT center leaders to draft an Inclusive Language Policy for the medical center that outlined the necessary changes to forms, electronic systems, and verbal communication standards.
  • Changing forms and ensuring adherence: Department managers and other administrative staff responsible for producing and revising forms made the requisite changes, following the requirements laid out in the aforementioned policy document. The medical center's forms committee took responsibility for monitoring adherence to the policy as a part of its regular forms review process.
  • Designing training program: LGBT center staff designed and implemented a dedicated training session to educate faculty and staff on implementing the language and policy changes.

Resources Used and Skills Needed

  • Staffing: A variety of staff and faculty from across the medical center created and implemented this program. Many of the changes were spearheaded by the former director of the LGBT center, who participated in the program as part of her regular job responsibilities. Frontline staff at the medical center follow the new policies and processes as a part of their regular job responsibilities.
  • Costs: The LGBT center has an annual budget of approximately $150,000 to $250,000, a portion of which supported program development and implementation.
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Funding Sources

University of California, San Francisco; California Endowment; California Wellness Foundation; Bay Area Physicians for Human Rights
The LGBT center receives some funding from UCSF's diversity and outreach office, with additional resources being provided by foundations and private donors.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Identify strengths and weaknesses: Review existing policies and practices to identify opportunities to improve the provision of welcoming, equitable care to LGBT patients. Even institutions that have made such issues a priority likely have room for improvement. For instance, many health care organizations that have nondiscrimination policies for lesbian and gay patients do not offer the same protections to transgender patients.
  • Make leadership commitment visible: Build staff and community support for prioritizing LGBT issues by visibly emphasizing leadership’s commitment to improvement. Include statements from key leaders in marketing materials and press releases that emphasize the importance of providing welcoming, equitable care for such patients.

Sustaining This Innovation

  • Focus on training: Successful implementation requires that staff have the requisite awareness, knowledge, and skills. To that end, make training and education available on an ongoing basis and in a number of formats, including online.
  • Ensure continued staff buy-in and adherence: Build internal committees or other structures to monitor adherence to policies. Keep staff engaged by providing ongoing support and information, including use of internal communication mechanisms (such as newsletters or intranet systems) to share stories of how welcoming and equitable care policies have affected the lives of individual patients.
  • Post policies publicly: Place copies of inclusive language standards in visible areas (including those accessible to patients) throughout the organization. These notices remind staff of their obligations to provide nondiscriminatory care and help LGBT patients feel safe and supported.

Spreading This Innovation

More than 100 health organizations through the United States, particularly those participating in the Healthcare Equality Index, have contacted the LGBT center for additional information about the program, and a number of them have adapted it to their institution’s needs.

More Information

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Contact the Innovator

Larry D. Lariosa, M.A.
Director of LGBT Resource Center/Diversity Manager
UCSF Medical Center
3333 California Street, Suite S-16
San Francisco, CA 94143
E-mail: Larry.Lariosa@ucsf.edu

Innovator Disclosures

Mr. Lariosa has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The Web site for the University of California, San Francisco LGBT Resource Center is available at: http://lgbt.ucsf.edu/.

The Healthcare Equality Index Web site is available at: http://www.hrc.org/hei.

Schonfeld AR. Self-assessment tool helps institutions meet sexual diversity needs in medical education. Academic Physician & Scientist. May 2, 2009.

The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the LGBT Community: A Field Guide. November 8, 2011. Available at: http://www.jointcommission.org/lgbt/.

Footnotes

1 When Health Care Isn't Caring. February 1, 2011. Available at: http://www.lambdalegal.org/publications/when-health-care-isnt-caring/.
2 Krehely J. How to close the LGBT health disparities gap. Center for American Progress. December 21, 2009. Available at: http://www.americanprogress.org/issues/lgbt/report/2009/12/21/7048/how-to-close-the-lgbt-health-disparities-gap
/
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3 Gay and Lesbian Medical Association. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual, and Transgender Health. San Francisco, CA: Gay and Lesbian Medical Association; 2001. Available at: http://www.glma.org/document
/docWindow.cfm?fuseaction=document.viewDocument&documentid=30&docu.mentFormatId=42
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4 Dean L, Meyer IH, Robinson K, et al. Lesbian, gay, bisexual, and transgender health: findings and concerns. J Gay Lesbian Med Assoc. 2000;4(3):101-51. Available at: http://www.glma.org/document
/docWindow.cfm?fuseaction=document.viewDocument&documentid=24&documentFormatId=34
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5 Nondiscrimination laws map. National Gay and Lesbian Task Force. July 1, 2009. Available at: http://www.thetaskforce.org/reports_and_research/nondiscrimination_laws.
6 New and revised hospital standards from The Joint Commission. Human Rights Campaign. Available at: http://www.hrc.org/files/assets/resources/health_jointcommissionperspectives_2010.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
7 Medicare proposes new rules to ensure equal visitation rights for all hospital patients. U.S. Department of Health and Human Services. June 23, 2010. Available at: http://www.fiercehealthcare.com/press-releases
/medicare-proposes-new-rules-ensure-equal-visitation-rights-all-hospital-patients
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8 Snowdon S. The medical school curriculum and LGBT health concerns. Virtual Mentor. 2010;12(8);638-43. Available at: http://virtualmentor.ama-assn.org/2010/08/medu1-1008.html.
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Original publication: September 11, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 19, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.