VA Health Care: Facilities Have Taken Action to Provide Language 
Access Services and Culturally Appropriate Care to a Diverse	 
Veteran Population (28-MAY-08, GAO-08-535).			 
                                                                 
The Department of Veterans Affairs (VA) faces challenges in	 
bridging language and cultural barriers as it seeks to provide	 
quality health care services to an increasingly diverse veteran  
population in terms of race, ethnicity, sex, and age. To meet the
needs of veterans with limited English proficiency (LEP), VA	 
issued an LEP Directive that provides guidance for medical	 
centers in assessing language needs and, if needed, developing	 
language access services designed to ensure effective		 
communication between English-speaking providers and those with  
LEP. In addition, VA is also challenged to deliver health care	 
services in ways that are culturally appropriate--that is,	 
respectful of and responsive to the cultural values of a diverse 
veteran population. In light of these challenges, GAO was asked  
to discuss the (1) actions VA has taken to implement its LEP	 
Directive and the status of veterans' utilization of language	 
access services, and (2) efforts VA has made to provide 	 
culturally appropriate health care services. GAO reviewed VA's	 
policies and the LEP Directive, interviewed VA officials and	 
reviewed efforts by 6 VA medical centers and 10 other VA	 
facilities to implement VA's LEP Directive and to provide	 
culturally appropriate health care services. GAO also reviewed	 
documents from 17 other VA medical centers related to		 
implementation of the LEP Directive.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-535 					        
    ACCNO:   A82226						        
  TITLE:     VA Health Care: Facilities Have Taken Action to Provide  
Language Access Services and Culturally Appropriate Care to a	 
Diverse Veteran Population					 
     DATE:   05/28/2008 
  SUBJECT:   Access to health care				 
	     Diversity management				 
	     Employee development				 
	     Employee training					 
	     Foreign languages					 
	     Health care facilities				 
	     Health care programs				 
	     Health care services				 
	     Health centers					 
	     Hospital care services				 
	     Military health services				 
	     Minorities 					 
	     On-the-job training				 
	     Patient care services				 
	     Training utilization				 
	     Veterans						 
	     Veterans benefits					 
	     Veterans hospitals 				 
	     Cultural awareness 				 

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GAO-08-535

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Report to Congressional Requesters: 

United States Government Accountability Office: 
GAO: 

May 2008: 

VA Health Care: 

Facilities Have Taken Action to Provide Language Access Services and 
Culturally Appropriate Care to a Diverse Veteran Population: 

This report includes a Spanish translation of the Highlights page, 
[hyperlink, http://www.gao.gov/highlights/d08535high.pdf]. 

Para ver la versiï¿½n de "Highlights" en inglï¿½s e espaï¿½ol, [hyperlink, 
http://www.gao.gov/highlights/d08535high.pdf], oprima aquï¿½. 

GAO-08-535: 

GAO Highlights: 

Highlights of GAO-08-535, a report to congressional requesters. 

Why GAO Did This Study: 

The Department of Veterans Affairs (VA) faces challenges in bridging 
language and cultural barriers as it seeks to provide quality health 
care services to an increasingly diverse veteran population in terms of 
race, ethnicity, sex, and age. To meet the needs of veterans with 
limited English proficiency (LEP), VA issued an LEP Directive that 
provides guidance for medical centers in assessing language needs and, 
if needed, developing language access services designed to ensure 
effective communication between English-speaking providers and those 
with LEP. In addition, VA is also challenged to deliver health care 
services in ways that are culturally appropriateï¿½that is, respectful of 
and responsive to the cultural values of a diverse veteran population. 
In light of these challenges, GAO was asked to discuss the (1) actions 
VA has taken to implement its LEP Directive and the status of veteransï¿½ 
utilization of language access services, and (2) efforts VA has made to 
provide culturally appropriate health care services. 

GAO reviewed VAï¿½s policies and the LEP Directive, interviewed VA 
officials and reviewed efforts by 6 VA medical centers and 10 other VA 
facilities to implement VAï¿½s LEP Directive and to provide culturally 
appropriate health care services. GAO also reviewed documents from 17 
other VA medical centers related to implementation of the LEP 
Directive. 

What GAO Found: 

VA reported that as of June 2007, all of its medical centers had taken 
action to implement the guidance in VAï¿½s LEP Directive. Specifically, 
medical center officials told VA that they had assessed the language 
needs of their veteran service populations, and, if necessary, 
developed language assistance policies and offered language access 
services, including providing translated materials and interpretation 
services. The VA medical centers GAO reviewed provided translated 
materials to meet the various language needs of their veteran service 
populations and offered interpretation services as well. For example, 
VA medical centers maintained a list of bilingual medical center staff 
who can provide interpretation services during a clinical encounter 
between a provider and a veteran with LEP. In addition, five of the six 
VA medical centers GAO reviewed can access telephone interpretation 
services that are provided through a contract to help ensure that 
medical staff can communicate with veterans and their families with 
LEP. According to officials at medical centers GAO reviewed, 
utilization of language access services is low. However, VA officials 
told GAO that they expect the demand for language access services to 
grow as the increasingly diverse military servicemember population 
transitions to veteran status. 

VA medical centers are addressing the need for culturally appropriate 
health care services through staff training and tailoring health care 
services. Medical centers provide training for medical center staff to 
facilitate the delivery of culturally appropriate health care services 
including an annual mandatory training on the health care needs of 
veterans in various age groups. VA medical centers and other VA 
facilities GAO reviewed have implemented a variety of measures to meet 
the needs of their culturally diverse veteran populations. For example, 
three VA facilities GAO reviewed offer spiritual services, such as the 
use of medicine men and traditional healing rituals, in order to meet 
the needs of Native American veterans. Also, VA has minority veterans 
program coordinators at each medical center to identify barriers to 
health care for minorities and advise medical center officials in 
developing services to make health care more accessible and culturally 
appropriate for minority veteran populations. VA medical centers GAO 
reviewed have also initiated outreach efforts to promote the 
availability of culturally appropriate care. 

In commenting on a draft of this report, VA stated that it agreed with 
the information presented as it pertained to VA. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-535]. For more 
information, contact Randall B. Williamson, (202) 512-7114, 
[email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

VA Medical Centers Are Implementing VA's LEP Directive; However, 
Utilization of Language Access Services Is Low: 

VA Medical Centers Are Addressing the Need for Culturally Appropriate 
Health Care Services through Staff Training and Tailoring Health Care 
Services: 

Agency Comments and Our Evaluation: 

Appendix I: GAO Contact and Staff Acknowledgments: 

Abbreviations: 

CBOC: community-based outpatient clinic 

CMV: Center for Minority Veterans: 

DOJ: Department of Justice: 

EEO: Equal Employment Opportunity: 

EO: executive order: 

HHS: Department of Health and Human Services: 

LEP: limited English proficiency: 

NDAA: National Defense Authorization Act: 

VA: Department of Veterans Affairs: 

VHA: Veterans Health Administration: 

VISN: Veterans Integrated Service Network: 

[End of section] 

United States Government Accountability Office: Washington, DC 20548: 

May 28, 2008: 

The Honorable Michael H. Michaud: 
Chairman: 
Subcommittee on Health: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Honorable John T. Salazar: 
House of Representatives: 

The Honorable Hilda L. Solis: 
House of Representatives: 

The veteran population served by the Department of Veterans Affairs 
(VA) will become more diverse in terms of race, ethnicity, sex, and 
age. VA data show that racial and ethnic minorities account for about 
20 percent of the veteran population and that about 7 percent of 
veterans are women.[Footnote 1] We reported in 2005 that racial and 
ethnic minorities accounted for about 33 percent of servicemembers in 
the military; about 16 percent of servicemembers were women.[Footnote 
2] Based on the higher diversity among servicemembers in the military 
compared to veterans, VA officials anticipate that the veteran 
population eligible to receive health care services from VA will become 
more diverse as current members of the military are discharged or 
released from active duty and transition to veteran status. In addition 
to racial and ethnic diversity, VA has seen an increase in the number 
of younger Operation Enduring Freedom and Operation Iraqi Freedom 
veterans using VA health care services and officials expect this number 
to continue to grow. 

As its veteran population becomes more diverse, VA faces challenges in 
bridging language and cultural barriers as it seeks to provide quality 
health care services to its veteran population. For example, a study 
commissioned by the California Endowment and the Robert Wood Johnson 
Foundation found that to help meet the needs of a diverse patient 
population, health care institutions, such as VA medical facilities, 
should provide language access services.[Footnote 3] Language access 
services are designed to ensure effective communication between English 
speakers and those with limited English proficiency (LEP). This may 
include providing translated versions of informational brochures or 
consent forms and making staff available who can interpret providers' 
instructions for patients or their family members with LEP. Several 
studies have found that the implementation of language access services 
in health care settings can increase access to care, quality of care, 
and health outcomes.[Footnote 4] 

Research suggests that providing culturally appropriate health care 
services is an integral part of quality health care, and that cultural 
factors can have a significant influence on the delivery of health care 
services and can compromise access for culturally diverse 
populations.[Footnote 5] At the federal level, HHS has published a set 
of standards for medical facilities that state that health care 
services should be delivered in ways that are culturally appropriate-- 
that is, respectful of and responsive to the cultural values of a 
diverse population.[Footnote 6] This can mean, for example, recognizing 
the role of the extended family in medical decisions for a particular 
ethnic group and including these individuals in discussions of a 
patient's medical care and treatment. According to HHS's standards, 
providing culturally appropriate services to culturally diverse 
patients has the potential to improve access to care, quality of care, 
and ultimately, health outcomes. Prior to the enactment of the National 
Defense Authorization Act (NDAA) for Fiscal Year 2008, there was no 
specific statutory requirement for VA to provide culturally appropriate 
care. However, several provisions in the 2008 NDAA require the 
consideration of the gender-, ethnic group-, or age-specific needs of 
veterans, including a direction to provide age-appropriate nursing home 
care.[Footnote 7] 

To meet the needs of persons with LEP, the President issued an 
executive order[Footnote 8] in August 2000 that required all federal 
agencies to develop and implement a system by which persons with LEP 
can have meaningful access to the services provided by the agency. The 
order also instructs federal agencies to work to ensure that recipients 
of federal financial assistance provide meaningful access to their LEP 
applicants and beneficiaries. According to the order, each agency must 
develop a plan that outlines the steps the agency will take to ensure 
that persons with LEP have meaningful access to the programs and 
services it provides.[Footnote 9] In response to this order, in January 
2002, VA issued a directive of its own--referred to in this report as 
the LEP Directive[Footnote 10] --to assist VA programs, including its 
medical centers, in providing appropriate language access services for 
veterans with LEP. The LEP directive provides guidance to medical 
centers and other facilities within VA to help them comply with EO 
13166; medical centers and other facilities that do not adopt all of 
the specific practices outlined in the directive are not necessarily 
out of compliance with the executive order as long as medical center 
officials take reasonable steps to assess and meet the language needs 
of the veteran service population. Additionally, because the diversity 
of the veteran service population varies across VA medical centers, 
some medical centers may not have a need to take all the actions 
identified in VA's LEP Directive. 

In light of the increasing diversity of the veteran population in terms 
of race, ethnicity, sex, and age, you asked for information about the 
steps VA has taken to provide language access services for veterans and 
its efforts to deliver health care services in ways that are culturally 
appropriate for veterans' diverse cultural values. This report 
discusses the (1) actions VA has taken to implement its LEP Directive 
and the status of veterans' utilization of available language access 
services, and (2) efforts VA has made to provide culturally appropriate 
health care services. We did not assess VA's compliance with EO 13166 
and instead describe actions taken under VA's LEP Directive in response 
to EO 13166. 

To describe the actions VA has taken to implement its LEP Directive as 
well as veterans' utilization of available language access services and 
the efforts VA has made to provide culturally appropriate health care 
services, we reviewed an executive order, federal guidance, and VA 
policy and procedures. We also selected five Veterans Integrated 
Service Networks (VISN) to review.[Footnote 11] We selected these five 
VISNs based on the number of racial and ethnic minority veterans living 
in each VISN and geographic variation.[Footnote 12] Within these five 
VISNs we selected a judgmental sample of 16 VA facilities, including 
six VA medical centers, five community-based outpatient clinics (CBOC), 
and five Vet Centers, to include in our review.[Footnote 13] From our 
sample of VA facilities, we conducted site visits to medical centers 
and associated CBOCs, and Vet Centers, located in Chicago, Illinois; 
Durham, North Carolina; and Los Angeles, California. For the remainder 
of VA facilities in our sample, we conducted in-depth telephone 
interviews with medical center, CBOC, and Vet Center officials in Bath, 
New York; Prescott, Arizona; and Richmond, Virginia.[Footnote 14] We 
conducted in-depth interviews with VA officials and staff from each of 
the 16 VA facilities to learn about actions taken at their facility to 
provide language access services for veterans with LEP, the utilization 
of these services, and the efforts the facility has made to provide 
culturally appropriate health care services. At the six VA medical 
centers we reviewed in depth, we examined documents related to efforts 
by the centers to assess the language needs of their service population 
and, if necessary, provide language access services. In addition, we 
interviewed officials in each of the five VISNs we selected for review. 
The information we collected from the six medical centers and five 
VISNs we reviewed is not generalizable to all VISNs and VA medical 
centers. 

Additionally, in order to obtain information on the steps VA has taken 
through its medical centers to provide language access services under 
its LEP Directive, we selected a random sample of 20 VA medical centers 
and requested copies of language needs assessments conducted by medical 
center officials and language assistance policies.[Footnote 15] We 
received documentation from 17 of the 20 medical centers. We conducted 
follow-up with the three medical centers that did not provide 
documentation but did not receive the requested materials from them. We 
did not evaluate the quality of the language needs assessments or 
language access policies provided by the 17 medical centers or from the 
6 medical centers we visited or reviewed in depth. The information we 
collected from our sample of 17 medical centers is not generalizable to 
all VA medical centers. In addition to interviews we conducted with VA 
officials, we also interviewed officials from the Department of Justice 
(DOJ), as well as experts in the field of language access services and 
the provision of culturally competent health care services.[Footnote 
16] We conducted this performance audit from February 2007 through 
March 2008, in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings based on our audit objectives. 

Results in Brief: 

As of June 2007, all VA medical centers had taken actions to implement 
VA's LEP Directive, according to VA. Specifically, all medical centers 
had assessed the language needs of their veteran service populations, 
and if necessary developed language assistance policies, and offered 
language access services. These language access services mainly involve 
providing translated materials and interpretation services. In 
addition, we found that all VA medical centers have computer software 
that generates medical treatment consent forms in Spanish and 
additional software that allows VA staff to access patient education 
materials in languages other than English. Medical centers offered 
interpretation services as well. For example, the six medical centers 
we reviewed maintained a list of bilingual medical center staff who 
volunteered to provide interpretation services during a clinical 
encounter between a provider and a veteran with LEP. In addition, five 
of the six medical centers included in our in-depth review can access 
telephone interpretation services that are provided through a contract 
to ensure that medical staff can communicate with veterans with LEP and 
their families. VA medical center officials reported to us that current 
utilization of language access services is low. However, VA officials 
told us that they expect the demand for language access services to 
grow as the increasingly diverse military servicemember population 
transitions to veteran status. 

We found that the six VA medical centers we reviewed in depth are 
addressing the need for culturally appropriate health care services 
through staff training and tailoring health care services. The six 
medical centers we reviewed provided training for medical center staff 
to facilitate the delivery of culturally appropriate health care 
services, including a mandatory training on the health care needs of 
veterans in various age groups. We found that VA medical centers and 
other VA facilities we reviewed in depth implemented a variety of 
measures to meet the needs of their culturally diverse veteran 
populations. For example, some locations offered spiritual services to 
meet the needs of Native American veterans, including the use of 
medicine men and traditional healing rituals. Another offered a 
counseling group exclusively for African American veterans; another 
offered counseling groups specifically for women veterans. Also, 
minority veterans program coordinators at all VA medical centers are 
charged with identifying barriers to health care for minorities and 
advising medical center officials in developing services to make health 
care more accessible and culturally appropriate for minority veteran 
populations. Some VA medical centers have also initiated outreach 
efforts to promote the availability of culturally appropriate care. For 
example, at two VA medical centers we reviewed in depth, staff told us 
that they worked closely with military and National Guard bases located 
near the medical center to increase the awareness of VA health benefits 
among younger veterans and their families. According to VA officials, 
these outreach efforts helped younger veterans understand that VA 
serves veterans of all ages and from all military conflicts. 

In commenting on a draft of this report, VA stated that it agreed with 
the information presented as it pertained to VA. 

Background: 

EO 13166, Improving Access to Services for Persons with Limited English 
Proficiency, requires that all federal agencies take reasonable steps 
to ensure meaningful access to their programs and services for people 
with LEP. DOJ has issued guidance that spells out four factors agencies 
need to consider in determining whether they are taking reasonable 
steps in this regard: (1) the number or proportion of LEP persons in 
the eligible service population; (2) the frequency with which LEP 
individuals come in contact with the program; (3) the importance of the 
services provided by the program; and (4) the resources available. 
[Footnote 17] Reasonable steps to ensure meaningful access could 
include developing language access services and guidance for 
implementing these services. The EO required that each federal agency 
create a plan outlining steps it will take consistent with DOJ guidance 
to ensure meaningful access to its services by LEP individuals. The EO 
did not require DOJ to evaluate the plans or to monitor the 
implementation of these plans. 

In 2002, in response to EO 13166, VA created and implemented VHA 
Directive 2002-006. It provided a framework for VA medical centers to 
assess and determine if there was a need to develop language assistance 
policies and language access services. The medical centers retain 
flexibility to determine exactly how they will comply with the EO, but 
they must do so in accordance with the four factors as outlined by DOJ 
and reiterated in the LEP Directive. In February 2007, VA issued VHA 
Directive 2007-009, which renewed VA's guidance on language assistance 
policies.[Footnote 18] In its LEP Directive, VA outlined the steps that 
constitute an effective language assistance program at its medical 
centers, including an assessment of the language needs of the veteran 
population served and identification of the non-English languages 
encountered by medical center staff. If a VA medical center identifies 
a specific language need among its veteran service population, VA's LEP 
Directive also indicated that the medical center should develop and 
implement a language assistance policy to ensure meaningful 
communication. According to the directive, the policy should describe 
how the medical center plans to provide language access services and 
ensure that all veterans receive meaningful access to VA health care 
services, regardless of the veterans' level of English proficiency. 
VA's LEP Directive also provided medical centers with examples of ways 
to provide language access services--including, translating written 
materials,[Footnote 19] hiring bilingual staff, and contracting with 
interpreter services. 

VA's Equal Employment Opportunity (EEO) office is responsible for 
overseeing the implementation of VA's LEP Directive. As such, this 
office conducted surveys of VA medical centers to assess whether 
medical center officials were following the steps outlined in the LEP 
Directive, such as conducting an assessment of language needs, or 
otherwise taking reasonable steps to provide language access services 
for veterans being served. VA's Center for Minority Veterans (CMV) 
[Footnote 20] is also involved in helping medical centers meet the 
language and cultural needs of the veteran population. CMV is 
responsible for ensuring that eligible minority veterans receive VA 
benefits and services. 

Culturally appropriate health care is care that is respectful of and 
responsive to the cultural needs of patients. According to HHS, 
providing culturally appropriate services to culturally diverse 
patients has the potential to improve access to care, quality of care, 
and ultimately, health outcomes. HHS has published a set of standards 
[Footnote 21] for all medical facilities regarding the delivery of 
culturally appropriate care. Other national organizations also 
recognize the importance of culturally appropriate care and have 
established standards or recommendations for its provision. For 
example, the Joint Commission has standards related to culturally 
appropriate health care that must be met by hospitals, including VA 
medical centers, to receive accreditation.[Footnote 22] 

VA Medical Centers Are Implementing VA's LEP Directive; However, 
Utilization of Language Access Services Is Low: 

VA medical centers are implementing VA's LEP Directive in terms of 
assessing the language needs of its veteran service population, and, if 
necessary, developing language assistance policies. VA medical centers 
and facilities have offered language access services that include 
providing translated materials and interpretation services to meet the 
needs of veterans with LEP. VA medical center officials reported a low 
utilization of these language access services. However, VA and medical 
center officials told us that they expect the demand for language 
access services to grow as the increasingly diverse servicemember 
population transitions to veteran status. 

VA Medical Centers Have Implemented the LEP Directive: 

VA stated that by June 2007 all of its medical centers had taken 
actions to implement the guidance in VA's LEP Directive. According to 
VA, all of its medical centers have assessed the language needs of its 
veteran service population, and, as necessary, developed language 
assistance policies. Our visits to three VA medical centers and in- 
depth telephone interviews with staff at three VA medical centers 
provided a more detailed account of the variety of language access 
services being offered at VA medical centers. 

VA first surveyed each of VA's medical center directors in December 
2005 to assess if medical centers were following the guidance in VA's 
LEP Directive.[Footnote 23] The survey contained 10 "yes" or "no" 
questions to gauge the extent of medical centers' efforts to implement 
the LEP Directive. The questions ranged from issues such as overall 
language assistance policies to efforts to provide language access 
services. If a "no" response was provided for any question, the medical 
center directors completing the survey were instructed to indicate a 
tentative date by which they would take action to address the item. VA 
required medical center directors and VISN directors to ensure that the 
responses for individual medical centers were completed. However, VA 
did not require that VISN or medical center directors provide 
documentation to support their "yes" responses to the survey. 

The results of the 2005 survey showed that 65 percent of VA medical 
centers had assessed the language needs of their veteran service 
population and that 60 percent of the centers had developed a language 
assistance policy.[Footnote 24] While completing the survey, VA medical 
center directors reported information about other medical center 
efforts to meet the needs of LEP veterans, including efforts to 
translate documents and hire bilingual interpreters. For example, 87 
percent of VA medical center directors reported establishing a list of 
staff available for interpretation services and that 24 percent of VA 
medical centers had translated written documents into languages other 
than English. 

After conducting its initial survey, VA took several steps to help 
medical centers improve their efforts to implement the LEP Directive, 
according to a VA official. VA staff made follow-up calls to VA 
officials from the medical centers that did not respond to the survey 
or that were identified by the survey as not conducting efforts 
consistent with the LEP Directive.[Footnote 25] During these follow-up 
efforts, VA staff offered guidance to medical center officials on 
conducting language needs assessments and developing language 
assistance policies in ways that were consistent with the LEP 
Directive. According to officials we interviewed at two VA medical 
centers, the guidance was helpful in their facilities' assessment of 
language needs among their service population and development of 
language assistance policies. 

According to VA, the follow-up efforts proved successful, as all 
medical centers reported that they had assessed the language needs of 
their veteran service population, and, as necessary, developed language 
assistance policies. In July 2007, VA reported that as a result of its 
follow-up efforts, all of VA's medical centers, in accordance with the 
LEP Directive, had assessed the language needs of their veteran service 
population and developed language assistance policies as needed. VA 
concluded that because of the progress and efforts made by its medical 
centers to implement the LEP Directive, VA would not conduct any 
additional evaluations of medical center implementation of the LEP 
Directive. Instead, VA said it would rely on the medical centers to 
monitor their own LEP language access needs and programs. 

VA Medical Centers and Facilities Offer a Variety of Language Access 
Services for Veterans with LEP: 

VA medical centers and other VA facilities have access to a variety of 
translation services. At the national level, VA has translated its 
widely distributed benefits publication into Spanish and makes 
information from this publication available in Spanish on its Web site. 
[Footnote 26] All VA medical centers have computer software that offers 
medical treatment consent forms in Spanish and additional software that 
allows VA staff to access patient education materials in several 
languages other than English, such as Spanish and Korean.[Footnote 27] 

The VA medical centers and facilities included in our in-depth review 
also provide translated materials to meet the various language needs of 
their veteran service populations. We found that all six medical 
centers in our in-depth review translate written materials on their 
own. For example, staff at one medical center we interviewed told us 
that they translated educational materials on traumatic brain injuries 
into Spanish. However, staff at the medical centers reported that they 
primarily rely on publicly available translated documents rather than 
translating written materials on their own because of the cost of 
independently translating documents. The sources of these publicly 
available materials range from other federal agencies to results of an 
Internet search. For example, according to VA officials, patient 
educators at some medical centers use patient education materials on a 
range of topics including heart disease and diabetes that have been 
translated into Spanish by HHS's Food and Drug Administration. VA 
medical center staff can also use materials translated by staff at 
other medical centers. For example, staff at one medical facility we 
reviewed reported that the VA medical center located in San Juan, 
Puerto Rico, has shared patient education materials they have 
translated into Spanish with other VA medical centers. Medical center 
staff we interviewed also reported using professional groups within VA, 
such as EEO managers or patient educators, to identify and share 
existing translated materials. However, these groups are limited in 
their membership and, as such, might not be aware of all translated 
materials available at VA medical centers. Additionally, VA medical 
facilities included in our review generally offer translated materials 
specific to the services they provide, when needed. For example, one 
Vet Center we reviewed translated a pamphlet on post-traumatic stress 
disorder into Spanish for its largely Hispanic veteran service 
population. 

As part of language access services, VA medical centers we reviewed in 
depth provide language interpretation services to help address the 
language needs of veterans with LEP. Staff we interviewed at all six 
medical centers we reviewed had the ability to provide interpretation 
services to veterans with LEP and were doing so in several different 
ways. For example, staff members at all six of these medical centers 
maintained a list of bilingual medical center staff who volunteered to 
provide interpretation services during a clinical encounter between a 
provider and a veteran with LEP. Medical center staff primarily used 
people from this list to provide needed interpretation services. In 
addition, staff at five of the six VA medical centers had contract 
telephone interpretation services available as a means to help 
effectively communicate with veterans and their families with LEP. 
Moreover, two of the three medical centers we visited advertised within 
the medical center, in languages other than English, the availability 
of language interpretation services to veterans and their families with 
LEP. In these medical centers, we observed signs posted near entrances 
and elevators that advertised, in multiple languages, free language 
interpretation services for veterans and their family members. 

In addition to efforts made by VA's medical centers to provide language 
access services, some of VA's Vet Centers have also made efforts to 
provide language access services to ensure that veterans with LEP have 
meaningful access to counseling and other services. Vet Centers provide 
language access services to veterans' family members with LEP to ensure 
that they are able to participate in counseling sessions, such as 
marital and family counseling. For example, at one Vet Center we 
visited, the entire staff was bilingual to help accommodate the needs 
of its mostly Hispanic veteran service population. In cases where 
bilingual staff were not available, four of the five Vet Centers where 
we conducted interviews had agreements with the local VA medical center 
to access its list of bilingual staff available for interpretation 
services. 

VA Medical Center Officials Report Low Utilization of Language Access 
Services; However, Officials Expect the Demand for These Services to 
Grow: 

Officials at the VA medical centers and facilities included in our in- 
depth review reported that veterans seldom use VA's language access 
services. For example, officials and staff we interviewed from five of 
the six medical centers in our review stated that their facility had a 
contract in place for telephone interpretation services but only one 
medical center reported ever utilizing these services. Staff at the 
medical center that reported utilizing the interpretation service 
stated that the use was infrequent. Moreover, staff we interviewed at 
the six VA medical centers we reviewed reported that most veterans 
speak English and staff at one medical center reported that veterans 
prefer to receive written materials in English. Staff at one medical 
center told us that they stopped routinely offering translated 
materials after veterans--for whom English was not their primary 
language--stated their preference for materials in English. However, 
translated documents were made available upon request. Despite the low 
utilization of interpretation services, such as the use of a contracted 
telephone interpretation service, officials at all six medical centers 
in our in-depth review reported using bilingual staff to serve as 
volunteer interpreters when needed.[Footnote 28] In addition, in our 
review of 17 other medical centers' language needs assessments, 
officials from one medical center volunteered utilizing telephone 
interpretation services four times in the 2 years prior to our request 
in July 2007, while another medical center volunteered in its 
assessment that veterans at the facility never used the facility's 
contracted telephone interpretation service. 

VA medical center officials told us that they expect the demand for 
language access services to grow as the increasingly diverse 
servicemember population transitions to veteran status. The 
servicemember population is more diverse--in terms of race, and 
ethnicity--than the current veteran population.[Footnote 29] VA 
officials we interviewed projected that the increased diversity of the 
military servicemember population will directly translate to an 
increased level of diversity in the veteran population as these 
servicemembers end their military careers and become veterans who may 
be eligible for VA health care services. Staff from several VA 
facilities told us that they have recently witnessed demographic 
changes in their service population. For example, two Vet Centers we 
visited told us that they have experienced an increase in the number of 
veterans and family members needing language access services in Spanish 
to facilitate marital and family counseling sessions. 

VA Medical Centers Are Addressing the Need for Culturally Appropriate 
Health Care Services through Staff Training and Tailoring Health Care 
Services: 

In an effort to address the cultural differences represented in its 
veteran service population, VA medical centers have conducted training 
programs to increase staff awareness about cultural diversity and the 
need for culturally appropriate health care services. Additionally, VA 
medical centers and facilities tailored a variety of health care 
services to different segments of the veteran population and promoted 
the availability of culturally appropriate health care services by 
targeting outreach efforts to different segments of the veteran 
population. 

VA Medical Centers Provided Training to Staff to Increase Awareness 
about the Need for Culturally Appropriate Health Care Services: 

VA medical centers have provided a variety of training programs for 
staff to both raise cultural awareness and to assist medical center 
staff in providing culturally appropriate health care services. 
According to VA medical center officials we interviewed, medical center 
staff are required to annually complete one mandatory VA-developed 
training course on the health care needs of veterans of various age 
groups.[Footnote 30] The six VA medical centers we reviewed have 
offered training to help staff understand cultural diversity as well as 
appreciate the need for culturally appropriate health care. These 
training efforts included locally-developed training on diversity given 
to new staff during orientation and on-line diversity training that is 
available to all staff. One of the six medical centers we reviewed in 
depth also developed training to help staff better understand what it 
was like for a veteran in general to serve in the military, as well as 
what it was like for a veteran who served during a particular military 
service era, such as the Vietnam War. The training materials also 
provided information on the types of medical diagnoses that may be 
related to a veteran's service, such as exposure to environmental 
hazards. Additionally, individual medical centers developed programs 
designed to increase awareness of veteran diversity and different 
cultural practices. For example, four VA medical centers we reviewed 
reported using celebrations and events in conjunction with heritage 
months (e.g., African American Heritage Month and Women's History 
Month) as educational opportunities to increase medical center staff 
awareness of veteran cultures and diversity. Programs included 
speakers, cultural fairs, and presentations open to staff and veterans 
at the individual VA medical centers. 

VA Medical Centers and Facilities Have Provided Health Care Services 
Tailored to Meet the Needs of a Culturally Diverse Veteran Population: 

VA medical centers and facilities have provided numerous health care 
services designed to meet the needs of the culturally diverse veteran 
population that differs in terms of race, ethnicity, sex, as well as 
age. According to VA officials, these services have varied across VA 
medical centers, CBOCs, and Vet Centers, depending on the needs of the 
veteran populations served. During our in-depth review of 16 VA medical 
centers and facilities, officials identified a number of health care 
services that are provided in a culturally appropriate manner: 

* Two medical centers and one Vet Center offer spiritual services, 
which include the use of medicine men and traditional healing rituals, 
in order to meet the needs of Native American veterans. 

* Three medical centers and one CBOC have increased the use of modern 
technology, such as text-messaging appointment reminders, to 
communicate more effectively with younger veterans, who are typically 
accustomed to such means of communication. 

* One Vet Center offered a counseling group exclusively for African 
American veterans and one Vet Center offered counseling groups for 
women veterans. 

According to staff we interviewed, services tailored to different 
segments of the population are often designed using information gained 
from specific veteran requests, veteran focus groups, or through 
recommendations of special-emphasis population groups.[Footnote 31] 

To facilitate the delivery of culturally appropriate health care 
services, all VA medical centers have a minority veterans program 
coordinator.[Footnote 32] The role of the minority veterans program 
coordinator is to identify barriers to health care and advise medical 
center officials in developing services to make health care more 
accessible and culturally appropriate for minority veteran populations. 
Minority veterans program coordinators also work directly with minority 
veterans in an effort to facilitate access to and use of VA health care 
services. 

To promote the availability of culturally appropriate care, the six VA 
medical centers included in our in-depth review have implemented a 
variety of targeted outreach efforts to different veteran populations. 
For example, officials at two of the six medical centers we reviewed 
reported working closely with military and National Guard bases located 
near the medical center to increase awareness of VA health benefits 
among younger veterans and their families. According to VA staff, these 
outreach efforts helped younger veterans understand that VA was not 
just "their grandfather's VA" and that VA medical centers serve 
veterans from all military conflicts. At one medical center, officials 
we interviewed reported outreach efforts to help Hispanic, younger, and 
female veterans recognize when they might need medical services, for 
example treatment for post-traumatic stress disorder or depression. 
These outreach efforts included participating in community health fairs 
and ceremonies held to welcome home servicemembers from the combat 
theaters. VA staff said they tailored these efforts to different 
communities, and staff at one medical center reported including 
materials in Spanish. 

Agency Comments and Our Evaluation: 

VA reviewed a draft of this report and sent us comments by email. VA 
agreed with the information presented as it pertained to VA. In 
commenting on the development of resources and education to help 
facilitate the delivery of culturally competent care, VA noted that 
there are different solutions based on local needs and supports a 
multimodality strategy as opposed to a "one module fits all" approach. 
We agree and as we discussed in our report, VA medical facilities do 
conduct training for staff and tailor health care services in an effort 
to address the differing needs for culturally appropriate health care 
services in particular locations. These efforts and services are often 
locally developed in response to the characteristics and needs of the 
veteran population served. 

As arranged with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
after its issuance date. At that time, we will send copies of this 
report to the Secretary of Veterans Affairs. We will also provide 
copies to others upon request. In addition, the report is available at 
no charge on the GAO Web site at [hyperlink, http://www.gao.gov]. If 
you or your staff have any questions about this report, please contact 
me at (202) 512-7114 or [email protected]. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. GAO staff that made major contributions 
to this report are listed in appendix I. 

Signed by: 

Randall B. Williamson: 
Director, Health Care: 

[End of section] 

Appendix I: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Randall B. Williamson, (202) 512-7114 or [email protected]: 

Acknowledgments: 

In addition to the contact above, Marcia Mann, Assistant Director; 
Melanie Anne Egorin; Krister Friday; Adrienne Griffin; Samantha Poppe; 
and James Walker made contributions to this report. 

[End of section] 

Footnotes: 

[1] See Department of Veterans Affairs, VA Benefits & Health Care 
Utilization (Washington, D.C., 2007), and Department of Veterans 
Affairs, Women Veterans: Past, Present and Future (Washington, D.C., 
May 2005). VA data from 2007 show that about 80 percent of veterans are 
white, non-Hispanic; 11 percent are African American; 6 percent are 
Hispanic; and 4 percent are other racial groups. 

[2] See GAO, Military Personnel: Reporting Additional Servicemember 
Demographics Could Enhance Congressional Oversight, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-05-952] (Washington, D.C.: Sept. 
22, 2005). We reported that 67 percent of military servicemembers were 
white, non-Hispanic; 9 percent were Hispanic, 17 percent were African 
American; and 3 percent were Asian American/Pacific Islander. 

[3] See Grantmakers in Health, In the Right Words: Addressing Language 
and Culture in Providing Care (San Francisco, Calif., August 2003). 

[4] See Department of Health and Human Services (HHS), A Patient- 
Centered Guide to Implementing Language Access Services in Healthcare 
Organizations (Washington, D.C., September 2005); B. D. Smedley, A. Y. 
Stith, and A. R. Nelson, Unequal Treatment: Confronting Racial and 
Ethnic Disparities in Health Care, Institute of Medicine Report 
(Washington, D.C., 2003); Grantmakers in Health, In the Right Words; 
and Edward L. Martinez, Steve Hitov, and Mara Youdelman, Language 
Access in Health Care Statement of Principles: Explanatory Guide 
(Washington, D.C., October 2006, reissued November 2007). 

[5] See Institute of Medicine, Speaking of Health: Assessing Health 
Communication Strategies for Diverse Populations (Washington, D.C., 
2002), and The Henry J. Kaiser Family Foundation, Compendium of 
Cultural Competence Initiatives in Health Care (Washington, D.C., and 
Menlo Park, Calif., 2003). 

[6] HHS, Office of Minority Health, National Standards for Culturally 
and Linguistically Appropriate Services in Health Care (Washington, 
D.C., 2001). 

[7] See, for example, Pub. L. No. 110-181, ï¿½ï¿½ 1603, 1661, 1706, 122 
Stat. 3. 

[8] Exec. Order (EO) No. 13166, Improving Access to Services for 
Persons with Limited English Proficiency, 65 Fed. Reg. 50121 (Aug. 11, 
2000). 

[9] EO 13166 further states that these plans are to be consistent with 
the standards set forth in the Department of Justice (DOJ) guidance 
that was issued at the same time as the EO. See 65 Fed. Reg. 50123 
(Aug. 16, 2000). The steps outlined in the plans are required to be 
consistent with, and not unduly burdensome to, the fundamental mission 
of the agency. DOJ serves as the central repository for materials 
related to implementation of EO 13166, including agency plans. 

[10] In this report, the term "LEP Directive" refers to Veterans Health 
Administration (VHA) Directive 2002-006, Limited English Proficiency 
(LEP) Title VI Prohibition Against National Origin Discrimination in 
Federally-Conducted Programs and Activities and in Federal Financial 
Assisted Programs, renewed as VHA Directive 2007-009, unless otherwise 
noted. 

[11] VA organizes its medical facilities into 21 regional networks, 
called Veterans Integrated Service Networks (VISN). For this report, we 
focus exclusively on health care services provided by VA in its medical 
centers, community-based outpatient clinics (CBOC), and Vet Centers, 
which are federally-conducted programs. The scope of this report does 
not include recipients of financial assistance from VA. 

[12] There is geographic variation in this group of VISNs: VISN 2 
includes upstate New York; VISN 6 includes Richmond, Virginia, and 
Raleigh-Durham, North Carolina; VISN 12 includes Chicago, Illinois; 
VISN 18 includes northern Arizona; and VISN 22 includes the greater Los 
Angeles, California, area. There is also variation in the racial and 
ethnic composition of veteran service populations in each VISN. For 
example, VISN 22 has significant Hispanic, African American, Asian/ 
Pacific Islander, and Native American populations whereas the majority 
of veterans served in VISN 12 is Caucasian with smaller percentages of 
African American veterans. 

[13] VA's health care system includes different types of health care 
facilities, including medical centers and community-based outpatient 
clinics (CBOC). VA medical centers offer services that range from 
primary care to complex specialty care, such as cardiac or spinal cord 
injury. VA's CBOCs are an extension of VA medical centers and mainly 
provide primary care services. VA also operates Vet Centers, which 
offer counseling services, including psychological counseling and 
psychotherapy, to combat veterans and their family members. Vet Centers 
are the only VA medical facilities authorized to provide services to 
family members. Vet Centers operate outside of the VISN structure but 
coordinate veterans' services and outreach with nearby VA medical 
centers. 

[14] Specifically, we conducted site visits to Jesse Brown VA Medical 
Center, Auburn Gresham CBOC, and Chicago Vet Center in Illinois; Durham 
VA Medical Center, Raleigh CBOC, and Raleigh Vet Center in North 
Carolina; and West Los Angeles VA Medical Center, East Los Angeles 
CBOC, and East Los Angeles Vet Center in California. We conducted in- 
depth interviews with officials from Bath VA Medical Center, Rochester 
CBOC, and Rochester Vet Center in New York; Prescott VA Medical Center, 
Anthem CBOC, and Prescott Vet Center in Arizona; and Hunter Holmes 
McGuire Medical Center in Virginia. We conducted interviews with 
officials from the medical center in Richmond, Virginia, because the 
medical center operates one of four VA polytrauma centers that provide 
care to active duty servicemembers as well as veterans. We did not 
interview CBOC or Vet Center officials from the Richmond area. 

[15] This sample did not include the six medical centers that we 
visited or reviewed in depth. 

[16] We interviewed experts in the field including staff from HHS's 
Office of Minority Health; the National Health Law Program; and the 
National Center for Cultural Competence. 

[17] See 65 Fed. Reg. 50123 (Aug. 16, 2000). EO 13166 indicated that 
the agency plans for their own programs should be consistent with this 
DOJ guidance. 

[18] VHA Directive 2002-006 expired in January 2007. The current VHA 
Directive 2007-009, which contains the same guidance as the 2002 
directive, expires in February 2012. 

[19] VA's LEP Directive prescribes standards for written translations 
that, if implemented by medical centers, would constitute a "safe 
harbor" for the center. That is, VA will consider those facilities that 
adopt the LEP Directive's standards to be in compliance with EO 13166. 
For example, if a medical facility has a population of at least 3,000 
veterans with LEP who speak the same primary language that facility 
will be considered in compliance with the EO if it provides translated 
written materials including vital documents in that primary language. 

[20] The Veterans Benefits Improvement Act of 1994 required VA to 
create the CMV, which is organizationally aligned to VA's Office of the 
Secretary. See Pub. L. No. 103-446, ï¿½ 509, 108 Stat. 4645, 4665-66 
(codified as amended at 38 U.S.C. ï¿½ 317). As required by law, CMV's 
primary emphasis is on minority veterans, specifically veterans in the 
following groups: Pacific Islander, Asian American, African American, 
Hispanic/Latino, and Native American, including American Indian, Alaska 
Native, and Native Hawaiian. 

[21] HHS, Office of Minority Health, National Standards for Culturally 
and Linguistically Appropriate Services in Health Care (Washington, 
D.C., 2001). 

[22] The Joint Commission, previously known as the Joint Commission on 
Accreditation of Healthcare Organizations, is a not-for-profit 
organization that evaluates and accredits health care organizations 
throughout the United States to help assure the quality of care 
provided to patients. Accreditation is an assessment process by which 
an organization's performance is measured against certain standards 
defined by industry experts. VA requires its medical centers to obtain 
and maintain accreditation from the Joint Commission. 

[23] VA initiated its survey in response to a November 2005 letter from 
members of Congress to VA's Secretary, which requested that VA monitor 
the implementation of VA's LEP Directive to help ensure that medical 
center's actions were consistent with the steps outlined in the 
directive. 

[24] This survey showed that four of the medical centers we reviewed in 
depth assessed the language needs of their veteran service population 
and that three of the medical centers we reviewed in depth developed a 
language assistance policy. 

[25] Staff from VA's EEO office conducted the follow-up calls to VA 
medical centers. 

[26] Department of Veterans Affairs, Federal Benefits for Veterans and 
Dependents (Washington, D.C., 2008). This publication is available in 
Spanish at [hyperlink, http://www.va.gov/opa/vadocs/fedbensp.pdf] 
(accessed May 27, 2008). 

[27] The iMed Consent application allows VA medical center staff to 
create medical consent forms in Spanish. Similarly, the KRAMES-on- 
Demand program allows medical center staff to provide patient education 
materials in several languages other than English. KRAMES-on-demand 
provides all its education materials and drug information sheets in 
English and Spanish. Additionally, education materials covering 10 
critical health topics are available in 10 languages: English, Spanish, 
Armenian, Chinese, Farsi, Hmong, Korean, Russian, Tagalog, and 
Vietnamese. 

[28] According to VA medical center staff we interviewed, the use of 
volunteer staff interpreters is often not reported to medical center 
officials and as a result may be undercounted. 

[29] See [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-952] and 
Department of Veterans Affairs, VA Benefits & Health Utilization 
(Washington, D.C., 2007). 

[30] Training of medical center staff on the health care needs of 
various age groups is an accreditation requirement from The Joint 
Commission. VA established a Cultural Competency Taskforce to identify 
and provide resources and training materials to medical centers to help 
facilitate the delivery of culturally appropriate health care. The 
taskforce is reviewing training modules on culturally appropriate 
health care in an effort to find a module that can be distributed to 
all VA medical centers for use in their efforts to provide culturally 
appropriate health care to veterans. The taskforce began work in spring 
2006. 

[31] Special-emphasis population groups are advocacy groups comprised 
of VA staff and focus on understanding the needs and promoting 
awareness of certain groups including Native Americans, Asian Pacific/ 
Islanders, African Americans, Hispanics, women, and people with 
disabilities. 

[32] Minority veterans program coordinators have been placed at each VA 
medical center by CMV as part of its systemwide effort to improve 
services for minority veterans. 

[End of section] 

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