Virginia S. Tong, LMSW VP, Cultural Competence Oct. 19, 2010

1. Virginia S. Tong, LMSW VP, Cultural Competence Oct. 19, 2010 A COMPARISON OF PATIENT SATISFACTION BETWEEN CHINESE AND SPANISH SPEAKING PATIENTS IN AN AMBULATORY CLINIC

2. Total # of patients served in 2009 - 482,917

3. Demographics*: Ethnicity & Poverty Rate Brooklyn’s Chinatown: Fastest Growing Population In Brooklyn • Ethnicity • Latino/Hispanic 37% • Chinese 27% • Jewish Orthodox 10% • Arabic 7% • Russian 7% • Poverty Rate • Southwest Brooklyn 22.2% • United States 12.4% • * Source 2000 Census Data Largest Latino Population In Brooklyn Largest Arabic Community In NYC 28% of Residents Live Below 100% Federal Poverty Level * Lutheran Family Health Centers and Lutheran Medical Center

4. LHC is the largest employer in the community. Our employees reflect our patient population: We speak 73 languages We celebrate 30 ethnic and religious holidays

5. Introduction Patients’ experiences with health care providers influence their perception of health care quality. Surveys of these experiences determine whether HCP are meeting the needs of their patients and lead to improvements in care. Significant patient satisfaction difference between races, ethnicity and language level. Not represent actual differences in quality of care. Represent variations in perceptions, expectations, and questionnaire response styles depends on ethnic group, race, or English proficiency.

6. Background • Lutheran Family Health Center conducting patient satisfaction survey in 4 languages (Spanish, Chinese, Russian and Arabic) for many years • Cross cultural study of responses never done • Strange phenomenon at Brooklyn Chinese Family Health Center despite: • Totally bilingual/bicultural staff • standing room only patients • long waiting time for appointments • successful balance sheet LOWEST PATIENT SATISFACTION SCORES IN SYSTEM

7. Brooklyn Chinese Family Health Center

8. Research Project • Created Research Team to study problem • Min Kyung Zimilevich MD, Win Win Myint MD, Ana Guerra MD, Kell Julliard MA, Virginia Tong MSW, Anna Chu, RN • Departments of Family Medicine, Clinical Research Office and Cultural Competence

9. Goal To analyze dimensions of satisfaction related to culture and clinic performance. To determine if Chinese speaking patients consistently rate their satisfaction differently than Spanish speaking patients for comparable care.

10. Analysis of Research Studies Disparities in the perception of health care among different ethnic and racial groups Asian patients have lower level of satisfaction than other races. Hispanics who have lower English proficiency have lower level of satisfaction.

11. Methodology Compared satisfaction ratings in a clinic serving both Chinese and Spanish patients- Family Physician Health Center. Examined survey results from 2005 to 2007 grouped by primary language spoken by each patient. Rating choices were: Great, Good, Fair, Poor, Don’t know. Assessed survey questions re: appointments, registration, the facility, respect and safety, waiting time, and relationships with nurse/medical assistants and doctors. Chi square tests were used to determine difference in satisfaction by language. Alphas set at 0.05.

12. Family Physician Health Center

13. Family Physician Family Health Center • Approximately 25% Chinese and 50% Spanish speaking patients • Staff: Chinese and Spanish speakers, primary care providers predominantly English only speakers. • FPHC provides: Pediatric, Ob/GYN, and adult services.

14. Patient Satisfaction Survey – Primary Care TO OUR VALUED PATIENTS: Your comments are very important to us and will help us improve services. Is this your first visit to this Health Center? ………. Yes ○No ○ How are you doing in the following areas? Poor Fair Good Great Don’t know Easy of scheduling at the Health Center…….. ….,, ○ ○ ○ ○ ○ Cleanliness of the Health Center ………………………. ○ ○ ○ ○ ○ Our effort to treat all people with equality …… ○ ○ ○ ○ ○ Our effort to keep your personal information confidential …………………………….. ○ ○ ○ ○ ○ Our respect for your privacy in the exam room ○ ○ ○ ○ ○ Amount of time you wait to see your provider ○ ○ ○ ○ ○ Courtesy and friendliness of nursing staff … ○ ○ ○ ○ ○ Concern showed for your health problem …… ○ ○ ○ ○ ○ How well your doctor listens to you and answers your questions ………………………. ○ ○ ○ ○ ○ Your confidence in this doctor/provider ……. ○ ○ ○ ○ ○ Overall, the likelihood you would recommend this Center to others, if needed ………….. ○ ○ ○ ○ ○

15. Surveys studied Total of 273 patients responded the survey at the FPHC from 2005 to 2007. Among 273, 56 (20.5%) were Chinese speakers, and 113 (41.4%) were Spanish speakers.

16. Figure 1: Percentage of great scores between Chinese and Spanish speakers at FPHC during 2005 ~ 2007 * * * * * * * *

17. Figure 2: Percentage of great and good scores between Chinese and Spanish speakers at FPHC during 2005 ~ 2007 * *

18. Figure 3: Confidence in providers between Chinese and Spanish speakers at FPHC during 2005 ~ 2007 Great Great & Good ─▲─ Chinese −■− Spanish

19. Figure 4: Satisfaction with waiting time at the health center between Chinese and Spanish speakers at FPHC during 2005 ~ 2007 Great Great & Good ─▲─ Chinese −■− Spanish

20. Figure 5: Satisfaction with friendliness of Nurse/MA between Chinese and Spanish speakers at FPHC during 2005 ~ 2007 Great Great & Good ─▲─ Chinese −■− Spanish

21. Results Chinese speakers gave fewer “great” ratings of satisfaction and combined “great and good” ratings compared with Spanish speakers. The gap between “great” scores of Spanish speakers and Chinese speakers was consistently greater than between combined “great and good”. Multiple studies show level of satisfaction is greater if seen by physicians of their own race and culture.

22. Discussion Asian Americans are considerably less satisfied than other racial or ethnic groups in U.S. Our study confirm that Asian Americans, in this case Chinese, give lower ratings as compared to Hispanics → cultural practice Studies show that Asian Americans choose responses in the middle of the scale whereas Hispanics and Blacks display more extreme responses.

23. Discussion Hispanics in our study graded low satisfaction on waiting time but they were highly satisfied with the attention given by the provider. Level of empathy with patients determine level of satisfaction.

24. Limitations of study • Convenient sampling • Self- administered questionnaire • Semiannual survey only at FPHC • No data re: patient demographics sex, age, socioeconomic background, diagnosis, health insurance • unable to adjust for confounding factors related to patient satisfaction

25. Recommendations All pts graded low on waiting time, ability to schedule an appointment → need improvement. Both groups rated high their experience with MA/RN. Education to all staff to become culturally competent. Compare responses to different questions within a specific culture → can compare similar culture at different clinics. Need to develop validated culturally specific survey instruments.

26. Conclusion Chinese speaking patients in our study graded level of satisfaction significantly lower than Spanish speakers and more noticeable regarding scores of “great” than of “great and good” combined.

27. Conclusion • There are disparities in the perception of health care among different ethnic and racial groups • Asian patients have lower level of satisfaction than other races. • Hispanics who have lower English proficiency have lower level of satisfaction. • Patient Satisfaction surveys and results have cultural biases which need to be taken into account. • Recommendations to link reimbursement to patient satisfaction scores need to be reviewed for cultural bias and equity to providers serving diverse patients.

28. Thank you Questions or comments, please contact: Virginia S. Tong Vice President, Cultural Competence Lutheran HealthCare 5800 Third Avenue Brooklyn, N. Y. 11220 718-630-7236 / vtong@lmcmc.com