How Healthcare Organizations are Implementing Disability Accommodations for Effective Communication: A Qualitative Study

Abstract

Background:

Prior studies have documented that, despite federal mandates, clinicians infrequently provide accommodations which enable equitable healthcare engagement for patients with communication disabilities. To date, there has been a paucity of empirical research describing the organizational approach to implementing these accommodations. We asked US healthcare organizations how they were delivering these accommodations in the context of clinical care, what communication accommodations they provided, and what disability populations they addressed.

Methods:

We performed 19 qualitative interviews with disability coordinators representing 15 US healthcare organizations actively implementing communication accommodations. We used a conventional qualitative content analysis approach to code the data and derive themes.

Results:

We identified three major themes related to how US healthcare organizations are implementing the provision of this service: (1) operationalizing the delivery of communication accommodations in healthcare required executive leadership support and preparatory work at clinic and organization-levels; (2) the primary focus of communication accommodations was sign language interpreter services for Deaf patients and, secondarily, other hearing- and visual-related accommodations; and (3) providing communication accommodations for patients with speech, language, and cognitive disabilities was less frequent, but when done involved more than providing a single aid or service.

Conclusions:

These findings suggest that, in addition to individual clinician efforts, there are organization-level factors that impact consistent provision of communication accommodations across the full range of communication disabilities. Future research should investigate these factors and test targeted implementation strategies to promote equitable access to healthcare for all patients with communication disabilities.

More than 50 million individuals, comprising 20% of US adults, have communication disabilities (CDs) affecting verbal or written modalities.^1–4 This group includes people with hearing, vision, speech, language, and cognitive disabilities. Examples of contributing underlying conditions include acquired hearing loss, blindness and low vision, intellectual and developmental disabilities, brain injury, neurologic conditions, and head and neck cancer. Section 504 of the Rehabilitation Act, the Americans with Disabilities Act (ADA), and Section 1557 of the Affordable Care Act require healthcare organizations to provide effective communication through reasonable accommodations so these patients can have equal access to high quality and safe healthcare.^5–7 Additionally, The Joint Commission, in its voluntary Health Care Equity Certification, stipulates that organizations must document the provision of disability accommodations to qualify for certification.⁸ Examples of communication accommodations include sign language interpreters, documents in large print, use of plain language, allowing extra time in a visit, and providing a note taker.⁹ Despite these available protections, communication accommodations are rarely provided to patients in healthcare settings, and these failures represent the most common ADA compliance violations in healthcare.^10–18

Disability health equity is part of a larger national movement addressing social factors that affect equity in healthcare service delivery. Progress has been challenged by a lack of empirical research on how healthcare organizations are operationalizing these commitments.¹⁹ To date, studies documenting inadequate communication accommodations have focused on individual or clinician-level factors, and not on organization-level approaches.^10–17 In this study, we sought to determine how healthcare organizations are implementing communication accommodations to promote equitable access in clinical settings. We focused on organizations that were actively providing accommodations and asked how they were providing accommodations, what disability populations they addressed, and what accommodations they provided.

METHODS

Study Design

We used a qualitative exploratory study design. We conducted semi-structured interviews with staff who were responsible for accommodation services at their organizations. To obtain a comprehensive overview of the accommodations being offered, we reviewed the external-facing websites of participant organizations, as well as policy documents provided by participants. The study reporting follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.²⁰ The University of Vermont Institutional Review Board approved all study procedures.

Study Team

The research team included a speech-language pathologist (SLP) and health services researcher, a physician/health services researcher, an SLP, and an SLP/health services researcher and expert in disability access. All team members had experience and/or training in qualitative research methods.

Participant Recruitment and Data Collection

We recruited participating organizations through purposeful and chain sampling. Primary recruiting occurred through the Disability Equity Collaborative, a preexisting learning collaborative of disability coordinators representing healthcare organizations that were actively adopting accommodations. Potential participants were contacted through email. Recruitment ended once preliminary data analysis showed thematic saturation.

The primary author created an initial semi-structured interview guide informed by a review of the literature on disability accommodations provided in healthcare settings. Thereafter, other team members provided feedback and modified the guide. The primary author conducted semi-structured interviews between January and September 2022 via Zoom video conferencing. Following the first two interviews, the team reviewed the guide to assess the need for additional changes. Interviews lasted approximately 60 minutes and were recorded and transcribed verbatim. During each interview, participants were asked for any lists of accommodations provided.

Data Analysis

We used an inductive, conventional qualitative content analysis approach to describe the phenomena of healthcare organizations providing accommodations.²¹ The team independently coded transcripts and met as a group to discuss differences in coding. We modified the codebook as appropriate and, following reconciliation, merged coded transcripts. We double-coded six transcripts to create the final codebook. The primary author used this final codebook to code the remaining transcripts.

To derive themes, we first organized codes into clusters that were meaningful within the context of the study objectives. We then analyzed these clusters and derived themes that captured the full range of practices conveyed by all organizations. To create lists of accommodations, we collated the accommodations named in interviews by organization and added those listed in written materials given by participants. We ensured trustworthiness through several strategies.²² The primary investigator kept a self-reflexivity log documenting biases, preconceptions, and decision-making questions during the interview and coding process.²³ She discussed these reflections during regular team meetings. Additionally, team-based coding ensured reliability of the coding process and a close connection to the data.²⁴ NVivo 1.7.1²⁵ was used to organize coded data into clusters.

RESULTS

A total of 19 participants representing 15 healthcare organizations participated in interviews. Table 1 lists the characteristics of the organizations and the participants. All participants were designated primary points of contact related to disability accommodations at their organizations. Participants represented non-profit organizations located in all four regions of the United States (using US Census regional delineations), with nearly half located in the Northeast. Organization sizes ranged from 1 to 40 network-hospitals. Multiple participants acknowledged that their organizations began or bolstered provision of effective communication accommodations to address patient complaints or Department of Justice settlement requirements.

Table 1.

Description of Organizations

	US region	Size	Characteristics	Settings covered by participants	Accommodations offered
Organization 1	Northeast	1 hospital, 100 clinics	Nonprofit, Academic	Inpatient acute	Sign language interpreter, hearing amplifiers, amplified phones, clear masks, dry erase board, TTY* phone, captioned phone, large button phone, closed captioned TV
Organization 2	Midwest	15 hospitals 144 clinics	Nonprofit	System Level†	Sign language interpreter
Organization 3	Northeast	40 hospitals, 700 clinics	Nonprofit, Academic	System level	Sign language interpreter, dry erase boards, communication boards,‡ sensory kits, assistance with filling out forms, sound signaler
Organization 4	South	1 hospital, 7 clinics	Nonprofit, Community hospital	System level	Sign language interpreter, hearing amplifiers, dry erase boards, CART,§ speech-to-text device, qualified reader,# magnifiers, talking alarm clock
Organization 5	Northeast	1 hospital, 400 clinics	Nonprofit, Academic	Inpatient acute	Sign language interpreter, hearing amplifiers, CART, clear masks, audio translation of written materials, lip reader
Organization 6	South	1 hospital, 90 clinics	Nonprofit, Academic	Inpatient acute	Sign language interpreter, hearing amplifiers, communication board, clear masks
Organization 7	West	23 hospitals, 200 clinics	Nonprofit	System level	Sign language interpreter, assisted listening systems, audible and large print or reading assistance, speech-to-speech relay services, TTY
Organization 8	West	21 hospitals, 290 clinics	Nonprofit	System level	Sign language interpreter, hearing amplifiers, reading glasses, magnifier, pen light, signature guide,** dry erase board, communication boards, reading assistance of documents, note taker, Script talk read aloud prescription labels††
Organization 9	West	2 hospitals, 15 clinics	Nonprofit, Academic	Outpatient clinics	Sign language interpreter, hearing amplifiers, magnifier, dry erase board, signature guide
Organization 10	Northeast	1 hospital, 320 clinics	Nonprofit, Academic	Inpatient acute	Sign language interpreter, hearing amplifiers, communication boards, adapted nurse call lights, inpatient video phone, magnifier, visual stories,‡‡ CART, TTY, closed caption TV
Organization 11	Northeast	1 hospital, 11 clinics	Nonprofit	Inpatient acute	Sign language interpreter, hearing and phone amplifiers, dry erase boards, communication board, adapted nurse call lights,§§ notepads, caption telephones, TTY, video phones, visual-tactile alert system||
Organization 12	Northeast	1 hospital, no clinics	Nonprofit, Community hospital	Inpatient acute	Sign language interpreter, hearing amplifiers, voice amplifier
Organization 13	Midwest	1 hospital, 125 clinics	Nonprofit, Academic	Inpatient acute	Sign language interpreter, hearing amplifiers, hearing aid batteries, reading glasses, sunglasses, dry erase boards, fidget spinners, sensory devices, signature guides, dry erase boards, book lights, tactile dots to add to remote control for patients with vision loss
Organization 14	West	5 hospitals, 200 clinics	Nonprofit	System level	Sign language interpreter, hearing amplifiers, TTY phones, visual-tactile alert system, alarm clock with vibrator, lip readers, tactile interpreters for people who are deaf-blind, closed caption TV, Braille signage, assistance with reading patient forms and materials, document screen magnifiers
Organization 15	Northeast	1 hospital, 3 clinics	Nonprofit, Community hospital	System level	Sign language interpreter, hearing amplifiers, dry erase boards, visual-tactile alert system, communication boards, laminated signs for patients Deaf or hearing and visually impaired to post at bedside, CART, signature guide, talking alarm clock

^*A device used by individuals who are deaf, hard of hearing, or speech-impaired to communicate over the telephone. It consists of a keyboard and a display screen, and it allows users to type messages back and forth instead of speaking.

^†Participants who sat at the system level oversaw inpatient and outpatient settings in addition to advising executive and local leadership on communication accommodations.

^‡A sheet or board with pictures, words, and symbols that the user can point to, to communicate.

^§CART stands for communication assisted real-time transcription. It is instant translation of spoken language through a stenotype machine, notebook computer and real-time software for Deaf and hard of hearing individuals.

^|A communication device containing two keyboards and two screens, enabling persons with hearing disabilities to read messages typed by their communication partner.

^#A person knowledgeable about medical terms, often clinical staff, who reads written material out loud.

^**A tool with a narrow opening that fits over a signature line on a document.

^††A technology that allows prescription labels to be read aloud for individuals with visual disabilities.

^‡‡An series of pictures which depicts upcoming steps to prepare patients for upcoming medical tests or procedures.

^§§Nurse call lights are inpatient devices that the patient pushes to call for help from nursing staff. Adapted call lights for can make it easier for someone who is blind, low vision to find the button or trigger to call their nurse.

^||A communication system designed to alert individuals who are Deaf or hard of hearing to various events, such as alarms, door knocks, or phone calls, using visual and tactile cues instead of sound.

Participants had varying responsibilities. More than half (n = 11) were in managerial roles, typically related to language interpreter or registration/call center services. These participants reported that the implementation of communication accommodations had been added to their existing responsibilities and that clinicians had repeatedly reached out to them for help in the absence of more formally established services. Seven participants held disability-related job titles and acted in a consultant role regarding ADA compliance. One participant’s role was focused solely on serving patients with intellectual and developmental disabilities. While participants varied in their primary organizational role, all were either the primary or one of a few points of contact regarding disability accommodations within their organization.

As to our primary research question regarding how organizations were implementing communication accommodations, three major themes emerged: (1) operationalizing the delivery of accommodations in healthcare required executive leadership support and preparatory work at clinic and organization levels; (2) the primary focus of communication accommodations was sign language interpreter services for Deaf patients and secondarily, other hearing- and visual-related accommodations; and (3) providing communication accommodations for patients with speech and language and cognitive disabilities was less frequent, but when done involved more than providing a single aid or service. See Table 2.

Table 2.

Major Themes and Example Quotes on the Implementation of Disability Accommodations for Effective Communication in US Healthcare Organizations

Major theme	Example quotes
1) Operationalizing the delivery of accommodations in healthcare required executive leadership support and preparatory work at clinic and organization levels.	Leadership support I was at the system level. One of the things that we had were different groups would meet together. So for example, risk officers would meet quarterly. I worked hard to get into those groups⋯ I tried to get into every group I could⋯ I would also engage the compliance officers, if that worked at that particular affiliate. So if you bring the compliance officer in, they also have the ear of leadership. So some of those ways to resolve issues. And sometimes you just have to figure out the organization and how it works. (HCO 7)
	Operationalizing steps:
	Preparatory steps:
	Step 1: Stocking the aids and training clinical staff.
	Step 2: Identifying patients who need accommodations.
	Step 3: Alerting relevant staff and clinicians and preparing the accommodations.
	Final step: Delivery of the accommodation and documenting use by staff and clinicians.
2) The primary focus was sign language interpreter services for Deaf patients and secondarily, other hearing and visual-related accommodations.	We don’t have a solution for everything. If it’s sign language, we can reach out to the agency. If it’s a sound amplifier, we can provide a pocket talker. (HCO 5)
3) Providing communication accommodations for patients with speech and language and cognitive disabilities was less frequent, but when done involved more than providing a single aid or service.	One time, we had a guy who was in here last fall. He was Hebrew speaking only and had aphasia and he was getting a hip surgery ⋯ we actually found a communication board in Hebrew that we could provide to him. We basically taped off the important graphics that he wanted ⋯ so that he could point to those things when his brother wasn’t gonna be there with him. I mean, everything you just try to do to customize, whatever their particular need is at that time. (HCO 14)

Theme 1: Operationalizing the Delivery of Accommodations in Healthcare Required Executive Leadership Support and Preparatory Work at Clinic and Organization Levels

In most organizations, participants reported that their role was to support consistent delivery of accommodations by patient-facing staff and clinicians. To do this, they helped with behind-the-scenes, preparatory steps in providing accommodations.

Really one of the objectives is to make sure that when the provider enters the room, these things are already in place so that the provider can really do what it is that they need to do while they’re there. (HCO 15)

Participants emphasized the importance of systematic change, but also that developing these systems and leadership buy-in went hand in hand. Participants were at various stages of acquiring this buy-in. Those without organization-level systems said that it would take some incentive, such as federal violations, for leadership to take efforts more seriously.

The feeling that I’m getting when I’m trying to make some of these systematic changes is there won’t be the buy-in we need until or unless something really bad happens, whether that’s a lawsuit or a DOJ [Department of Justice] complaint. Or something to show that, yes, this is a big deal, and this is serious. (HCO 9)

Participants also attributed a lack of leadership support for systematic changes to erroneous beliefs that consistent and widespread delivery of accommodations across their organizations was easily accomplished in a single step.

So that’s really been my focus in the organization, is trying to make sure that leadership understands that need [to identify accommodation needs of all patients] and the various work streams that are involved in making improvements to our EHR [electronic health record], and then the various departments that are involved. (HCO 8a)

Conversely, leadership support was underscored as a key ingredient by participants whose institutions successfully achieved organization-level systems. For example, one participant identified higher-level leadership support as an inflection point in his efforts to implement a universal screening for accommodation needs by registration staff.

For the last four years, we’ve been working on this process. And for three years, the registration leadership was thinking, “Well, this is a clinical question. This really needs to be asked by clinical staff.” … So the way our leadership works, our department reports to the Vice President of Risk Management and Disability Services. So, it really was her leadership saying, “This is just how it’s going to be, and this is why it has to be.” And the registration leadership saying, “That sounds like a great idea.” It was an epiphany, essentially. (HCO 3)

Participants described three common preparatory steps that ultimately led to the provision of accommodations by patient-facing staff and clinicians.

Preparatory Step 1: Stocking the Aids and Training Clinical Staff

Many participants reported that a key part of their job was maintaining the supply of communication aids. Some participants were in charge of a central supply of aids for their whole organization. Many others said that local wards and clinics maintained their own toolkits of basic aids such as hearing amplifiers, dry erase boards, magnifiers, and signature guides. Participants audited the kits to ensure they were ready for use when a patient need arose. Funding to supply the aids came from diverse sources—from internal grants, to centralized budgets, to a patchwork of internal sources such as Rehabilitation Therapies, Patient Relations, and Audiology.

Another essential step was training staff and clinicians on when and how to use the aids to facilitate communication with patients. Participants reported challenges in getting educational time at an organization-level, such as mandatory trainings. One participant attributed inconsistent provision of communication accommodations to a lack of organizationwide trainings, “That’s probably half the battle…that people are not educated or [are] ignorant about what’s available.”

Preparatory Step 2: Identifying Patients Who Need Accommodations.

All participants reported that before an accommodation can be provided, patients in need must be identified. Four participants reported having organization-level supports for this step through a standard screening process conducted by registration staff.

When we register a patient, of course we have their name and their basic demographic information. And in addition to preferred language, … we also have a drop-down of “Can we provide an accommodation for you?” So, we screen all of our patients, and then we list all of our auxiliary aids. (HCO 11)

Other participants reported that identification relied on individual clinicians and patients identifying a need in the context of medical care: “A lot of it comes from the clinics or healthcare providers … when they realize that they have a patient with a disability that might need a certain accommodation.” While patients themselves could advocate for their accommodation needs, several participants noted that this was not an ideal method for identifying needs. “Sometimes our patients are not great advocates for themselves, or they just don’t even know that there’s accommodations available.” Participants expressed wanting to have organization-level systems so that all patients were asked if they had an accommodation need and no one was missed.

Preparatory Step 3: Alerting Relevant Staff and Clinicians and Preparing the Accommodations

In addition to a lack of systems to identify patients with accommodation needs, the majority of participants said they did not have standardized systems to alert relevant staff and clinicians ahead of the patient’s medical encounter.

Right now, I feel very lucky if I know ahead of time that someone will need an accommodation. … How can we alert all of the teams that will come in contact with a patient on clinic day, starting with transport, so that everyone knows, okay, this person’s going to need whatever tool to communicate, and this is how we’re going to get it to them. We still have a lot of work there to do. (HCO 6)

Of the participants whose institutions had organization-level systems for identifying needs, a few carried these systems through to preparation of accommodations. One participant described a workflow in their inpatient setting.

We send out a report that says, “This is your current admission status of your patients that have a completed (intake) document.” So it’s going to identify, “Do they need communication assistance?⋯” And that information gets sent out to what we call our disability champions and our 504 coordinators. (HCO 3)

Another participant described clinic-level workflows standardized across her organization.

Every morning, the manager of each outpatient location prints a daily report of the patient panel of the day⋯ and there’s a section, a column, that’s labeled “notes.” … this is where you’ll see identified language or accommodation needs. And that gives them ample time to be able to say, “Oh, okay. 9:00 needs a pocket talker or 10:00, there’s an ASL interpreter that’s going to be here…so the medical assistant has ample opportunity to get the accommodation ready.’’ (HCO 11)

Final step: Delivery of the Accommodation and Documenting Use by Clinical Staff

Regardless of systems to identify needs and prepare communication accommodations, all participants said that patient-facing staff and clinicians were responsible for the final step of providing accommodations at the point of care. “We have the identification of the need, and then setting up the accommodation. But then the services rendered is then at that end user point.” Participants reported limited resources to systematically check this step. “I have no way to know if they’re [healthcare staff and clinicians] using them [the aids] appropriately or when they should. We just offer them the tools.” While clinicians were advised to document provision, organizations did not monitor this documentation. However, participants said they were in close communication with their patient advocacy or patient experience departments to monitor patient complaints related to disability access.

Theme 2: The Primary Focus Was Sign Language Interpreter Services for Deaf Patients and Secondarily, Other Hearing- and Visual-Related Accommodations

All participating organizations offered sign language interpreter services—typically American Sign Language (ASL)—and participants reported this service had a high level of systemic support relative to other accommodations (Table 1). “Our priority over the past two years has been really maintaining that standardization in the language (interpreter) piece of it. So, we really are in the infancy of the disability component of it.” Participants said that sign language interpreter services followed the language interpreter workflows such as universal screening at registration. Despite the observed gap between provision of sign language interpreter services and other communication accommodations, participants consistently acknowledged the importance of accommodating all patients with CDs.

That process is pretty formalized for interpreter services (including ASL), but not for the (communication) auxiliary aids and services, and I think it’s just as important. (HCO 15)

The next most frequently described aids and services were for patients with other hearing disabilities, including Deaf patients who do not communicate via ASL, and patients with visual disabilities. Under the category of aids, almost all participants said that their organizations had hearing amplification devices for in-person or phone communications. Examples of other aids offered inconsistently were communication assisted real-time transcription (CART) services, where a transcriptionist types out the verbal exchange of information for Deaf patients who don’t use ASL, having someone available to read documents, and having someone available to take notes in an appointment.

Theme 3: Providing Communication Accommodations for Patients with Speech and Language and Cognitive Disabilities Was Less Frequent, But When Done, Involved More Than Providing a Single Aid or Service

Participants acknowledged that providing hearing and visual-related accommodations did not meet the needs of all patients with CDs. However, participants said they were not trained to address speech and language and cognitive disabilities. For example, when asked about accommodating patients with aphasia, a participant said, “We don’t have many solutions for those patients,” but explained that her lip reading specialists have helped with these patients in the past. Participants sought extra training and welcomed collaborations with skilled providers within their organization. For example, a participant whose scope was limited to patients with hearing disabilities said she has considered expanding accommodations beyond hearing and visual disabilities but a prerequisite to expansion would be enrolling additional support from communication healthcare professionals at her organization.

We would need to up our game a little bit, or bring on somebody who had more expertise in that area, like perhaps an Audiologist or SLP … That’s, that’s kind of their world, you know? (HCO 1)

The few participants who could speak to providing accommodations to patients with speech and language and cognitive disabilities described customized instances rather than workflows. The accommodations they described could be characterized by clinicians adapting their usual mode of communication. For example, one participant recalled instances during COVID where she helped nurses in the ICU communicate with patients with speech and language difficulties after neurologic injury and mechanical ventilation.

They bring this person in, airlift them in after their stroke and there’s no family … We work with the nurses, we figure this out. We teach them how best to communicate. What do the different signs mean? What do the different gestures mean? … Okay. Let’s do a “yes or no” piece of paper. Look this way for yes. Look this way for no. (HCO 13)

Two participants also described modifying policies and processes of care for this group of patients. For example, providing extra time in an appointment or ensuring that family member was allowed to be present at all steps in a care process. They observed that these types of accommodations were harder to standardize.

And so for these other types of things (accommodations), it’s really unfortunately hit or miss … So we’re trying to figure out ways to make it a little bit more procedural to where we can come up with something that would be somewhat standardized. (HCO 9)

One participant stood out as unique because her entire role centered on accommodating patients with a combination of speech, language, and cognitive disabilities—people with intellectual and developmental disabilities and autistic people. This participant developed a standardized process for her work and created individualized care plans of accommodations, housed in the patient’s record. Patient-facing staff and clinicians were trained to look for these care plans and typically executed the accommodations. For example, she described her plan to coordinate accommodations for a nonspeaking autistic patient with intellectual disabilities:

I’ll set up an escort for him with our police and security office, who can then help to expedite so there’s no waiting. Provide a private elevator… And he’s nonverbal and can really read the emotions and very perceptive about that. But also has receptive challenges, so he needs kind of less is more…So just better to kind of keep it simple, whereas other patients, even when they’re a nonverbal communicator, still might enjoy extra attention or connecting with them directly. (HCO 10a)

DISCUSSION

This sample of nineteen disability coordinators, representing fifteen US healthcare organizations at the forefront of providing communication accommodations, provided their perspectives on organizational approaches to implementing accommodations. Participants described common preparatory steps in operationalizing day-to-day provision of accommodations and variable levels of organization-level systems underlying these steps. They identified that while system-level workflows were needed, leadership knowledge and buy-in was a limiting factor. The exception to this was sign language interpreter services, which had mature organization-level systems to identify all patients with needs and provide services. Beyond sign language services, participating institutions commonly focused on other hearing and secondarily, visual accommodations. Accommodations for speech, language, and cognitive disabilities were less consistently offered and required a more tailored approach.

To our knowledge, this study is the first to describe how US healthcare organizations are implementing accommodations for effective communication. Our study fills a gap in prior literature that indicates that despite legal mandates, clinicians do not reliably accommodate patients with CDs.^{12,13,15,16,26,27} These studies have placed the onus for change on clinicians, identifying a need to increase clinician training and knowledge around disability accommodations.^14,28,29 Our findings underscore that even among leading organizations, communication accommodations frequently lack standardized, organization-level workflows to reliably identify and provide accommodations to all CD groups. Without these insights, future interventions will mistakenly focus on clinicians as the sole agent of change. This is especially true in today’s landscape of increasing integration of physician practices into provider organizations and hospital systems.^30,31 Our participants underscored that leadership buy-in was critical to attaining these organization-level systems. This aligns with prior sentiment that financial or legal incentives may be key factors in advancing the state of disability accommodations.²⁹

Our pattern of findings indicates that implementation complexity may be a major driver in what communication accommodations are consistently being provided. First, in line with prior findings of disability accommodations in federally qualified health centers,³² sign language interpreter services were most consistently provided relative to other accommodations. Implementing this accommodation was straightforward as it fell into pre-existing, language interpreter service workflows. The second most commonly provided group of communication accommodations were things or services that could be delivered to patients off-the-shelf, without further customization; examples included hearing amplifiers or live transcriptionist services. Last, the accommodations that were rarely provided were those that required customization; examples included modifying a clinical workflow to enable an extended appointment time or clinicians modifying their communication style. Providing this group of accommodations across entire inpatient or outpatient systems is a formidable challenge in terms of scale. Unfortunately, this also means that individuals who require these customized accommodations, those with speech and language and cognitive disabilities, are infrequently accommodated.

In this context, it appears the science needed to achieve accessible and high-quality care for all patients with CDs is not biomedical, but rather implementation. Implementation science is the study of methods to promote the systematic uptake of evidence informed practices to improve the quality and effectiveness of health services.³³ This challenge for healthcare organizations may come with more incentives in the coming years. In 2023, the Department of Health and Human Services (HHS) published a proposed rule, which, in line with our findings, identified that accommodations for people with cognitive and speech and language disabilities are unique in needing to incorporate more specialized alternative and augmentative communication devices and may require modification of policies, practices, or procedures to prevent discrimination on the basis of a CD. The rule emphasized that despite these differences, this group is equally covered under accommodation mandates.³⁴

Limitations

Our findings should be considered in the context of their limitations. We obtained organization-level data through the institution’s primary point of contact for accommodations, disability coordinators. These perspectives may not be representative of all individuals involved in accommodations at these institutions. Additionally, our findings are unique to institutions actively engaged in providing accommodations and are not meant to generalize to a random sampling of organizations. Finally, the senior author is the primary coordinator of the Disability Equity Collaborative group, which may have contributed to a social desirability bias reflected in responses. Despite this, we experienced that prior rapport established with participants opened lines of honest communication on a potentially sensitive subject with significant regulatory and legal implications.

CONCLUSIONS

These findings suggest that, in addition to individual clinician efforts, there are organization-level factors that impact consistent provision of communication accommodations across the full range of communication disabilities. Future research should investigate these factors and test targeted implementation strategies to promote equitable access to healthcare for all patients with communication disabilities.