Removing Barriers to Health Care
A Guide for Health Professionals
Produced by: The Center for Universal Design and The North Carolina Office on Disability and Health
(Booklet copies of Removing Barriers to Health Care may be ordered from The Center for Universal Design and The North Carolina Office on Disability and Health (Addresses are at the end of this document). Alternate formats are available upon request.)
Content of Document
Scope of the Problem | Providing Universal Access | Recommended Universal Design Features | Creating Accessible Environments and Services | Selected ADA requirements for health care providers | Create a Team of People | Providing Customer-based Services
Universal Design: The concept of designing all products and the built environment to be aesthetic and usable to the greatest extent possible by everyone, regardless of their age, ability, or status in life.
This document provides guidelines and recommendations to help health care professionals ensure equal use of the facility and services by all their patients. The information in this guide gives health care providers a better understanding of how to improve not only the physical environment, but also their personal interactions with patients with disabilities. There is also a review of some of the design standards established through state and federal laws, such as the Americans with Disabilities Act (ADA), that health care professionals need to know.
- How usable are your health care services and facilities to people with disabilities?
- Can you weigh people who can't stand on the scale?
- Can you communicate with patients with hearing disabilities?
- Is it easy for your patients to move freely throughout your facility?
This guide encourages health care professionals to go beyond the minimum requirements set by law to make facilities and services universally usable to the greatest extent possible. By meeting the needs of people with disabilities, you will also be providing enhanced facilities and services to all your patients.
Scope of the Problem:
People with disabilities represent a large and growing sector of the population that needs health care services. While over 54 million Americans have been identified as being disabled, the true number of people with a disability is unknown. At some point, almost everyone experiences a disability as they age.
However, many people with disabilities do not seek out or obtain quality health care. Often, health care facilities are not accessible or do not have the equipment needed to serve people with disabilities. Also, people are often embarrassed because their disability requires them to obtain additional assistance from the staff, requiring them to surrender some of their independence. Sometimes, staff may not know how to assist a person with a disability, causing frustration for both the patient and the staff member. As a result, some people with disabilities only pursue medical attention for emergency or acute conditions, making primary and preventive health care services low priorities.
From the provider's perspective, limitations in the physical environment, such as the lack of appropriate equipment, may cause doctors and other professionals to forgo, omit, or not recommend procedures or portions of procedures for people with disabilities that would otherwise be commonplace. Increasing accessibility at health care facilities will encourage more people to seek out services, thus increasing client bases as well as the general health of individuals with disabilities.
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Providing Universal Access
Universal access or universal design is a concept, that, when applied to environments, ensures that facilities, products, and services are usable by all people. Everyone, regardless of ability, benefits from universal design. Wide doors make moving equipment and furniture easier for everyone. Spacious toilet rooms provide space for wheelchair users but also accommodate parents with strollers or several children. A place to sit while transacting business is good for anyone when they are tired, not feeling well, or pregnant. Recommended universal design features, such as power door operators and adjustable-height examining and treatment tables, work well for everyone including children and older adults.
Some people-accommodating features also add to the value of the property, create a more interactive environment, relieve staff of unnecessary extra work, and help maintain a comfortable place to work and visit. Going beyond the minimum requirements makes your facility more usable for all patients. Following is a checklist of ways to improve usability and broaden participation in health care.
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Recommended Universal Design Features
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- Weather protection at entrance doors
- Power door operators at interior and exterior entrances
- Spaces left open but dispersed in waiting areas where wheelchair users can sit out of traffic lanes but with other people.
- Chairs for use by people who cannot stand while transacting business
- Chairs that can be set at different heights for use by children, adults and older people, some equipped with arm rests for those who need assistance rising to their feet
- Scales that allow people with difficulty standing to hold on, and one that allows people to be weighed while sitting in a wheelchair
- Motorized, adjustable-height treatment and examining tables and chairs (view examination area)
- Mammography machines that can be used on a woman in a seated position
- A portable, amplified communication system or device with volume control at service desks and treatment spaces for people who are hard of hearing
- More than one accessible toilet and dressing room, some left-handed and some right-handed
- A TTY for use by people who are deaf to make phone calls from health care facilities
- Staff awareness and training in using the National Telephone Relay System
- Awareness and sensitivity training for all staff and professional personnel on interacting with people with disabilities
Creating Accessible Environments and Services
Creating accessible health care environments does not have to be expensive. In new construction, accessibility features generally do not increase costs. In fact, even in existing facilities, necessary modifications are not always expensive. And there may be alternative devices or services that can be used as interim solutions when needed changes may not be readily achievable.
Following are some guidelines for creating and modifying health care facilities to be accessible to people with disabilities. By integrating usable environments beneficial to all your consumers.
Learn and Adhere to Codes and Laws Regarding Accessibility:
Many different local and state building codes, as well as civil rights laws, address accessibility. When building, buying, remodeling or furnishing facilities, health care providers are responsible for ensuring their facilities adhere to all accessibility requirements. Because there is no plan review or approval and permit process for accessibility requirements, health care practitioners may not know their obligations and liability. One must not assume that contractors are aware of and will address all required obligations. Following are some of the laws and codes you need to become familiar with to ensure you are in compliance with accessibility regulations.
The Americans with Disabilities Act:
The Americans with Disabilities Act (ADA) is a federal law that prohibits discrimination against, or segregation of, people with disabilities in all activities, programs, or services. While the ADA is similar to and patterned after other civil rights laws, it differs in that it also has a major impact on the design, construction, and operation of buildings and facilities, transportation vehicles, and many of the products that go into them.
The regulations for implementing the ADA include a broad set of building design specifications for new construction, additions, and remodeling called the Americans with Disabilities Act Standards for Accessible Design. Due to their importance in the lives of people with disabilities, facilities providing health care are held to an even higher standard than other businesses. For example, in new construction, elevators waived for very small, two-story office buildings must be provided in health care office buildings of any size. The ADA Standards are being adopted and used as part of state, regional, and national building codes where they are becoming part of common practice for review, approval, and construction permits. Even without local adoption and enforcement, the regulations are mandatory and individuals may file complaints for non-compliance with owners, managers, and the U.S. Department of Justice.
Rehabilitation Act of 1973:
Section 504 of the federal Rehabilitation Act of 1973 requires that any program or service receiving federal financial assistance, either directly or indirectly, be accessible to everyone. Most public services fall in this category, including health care facilities. Meeting the requirements of Section 504 can be accomplished by changing policies, providing services such as sign-language interpreters, installing text telephones for deaf clients, or relocating the program to an accessible facility.
State and Local Building Codes:
Most states have building codes or other regulations that specify and require accessibility for people with disabilities in building design and construction. These vary in scope, detail, and enforcement. Some are local, city or county codes instead of statewide. Some states also have civil rights laws prohibiting discriminatory practices.
The following chart highlights some of the key ADA requirements that should not be overlooked. The illustrations that follow combine Universal Design Features with requirements of the ADA to depict environments that are safer and easier for all visitors, patients, and staff to use.
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Selected ADA requirements for health care providers:
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- Accessible parking spaces close to entrances (view parking diagram)
- Accessible front entrance with ramp and curb cut at appropriate grades and surfaces (view facility Entrance)
- Interior and exterior doors that are wide and easy to open
- Accessible route throughout the facility connecting all accessible features and service areas (view lobby and reception area)
- Clear floor space so people, even those using wheelchairs, can get close to and reach all controls and other features
- Controls, storage facilities and amenities such as magazine and literature racks within reach ranges for short people and wheelchair users
- Low counters, service windows or receptionist stations for transactions with short or seated people
- Desk-height writing surfaces with knee space for use by wheelchair users and others who cannot stand while transacting business
- Accessible toilet and dressing rooms large enough for a person using a wheelchair to navigate (view toilet room, view dressing room)
- Audible and visual alarm systems
- Qualified sign language interpreters for communication with people who are deaf
- Large printout capability of key papers and documents for people with low vision
- Raised lettering and Braille on selected signs such as room and elevator controls
Create a Team of People to Help Determine and Meet Accessibility Requirements:
Creating barrier-free health care environments is an ongoing process that requires input from many people. Designers, builders, and equipment suppliers do not set policies and are not taught to design for or accommodate the full range of human needs and abilities. Building codes and laws cannot correct for this deficiency, so it is important for health care professionals to become active team members in planning for any health care facility or program.
Involving people with a variety of disabilities as part of a team for assessing accessibility and recommending additional accommodations is essential. The lived experience of disability is an excellent resource. Since each person's experience and knowledge is different, and also because disabilities vary so broadly, seek advice from more than one person. Ask your patients for their input on how to make your facility and services more accessible. Local disability organizations or advocates can provide information on a broad range of disabilities including mobility, cognitive, vision, and hearing and are excellent sources for planning advice.
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Provide Customer-based Services:
Not all barriers to health care are physical ones. Often, interactions between health care providers and people with disabilities can be awkward and frustrating. Observing some basic rules of disability etiquette will yield greater results and more positive interactions between health care professionals and patients with disabilities.
People with Mobility Disabilities
- Treat all persons with respect. Call a person by his or her first name only when you're extending this familiarity to everyone present.
- Offer assistance to a person with a disability if you feel like it, but wait until your offer is accepted before you help, and listen to any instructions that person may want to give about the best way to assist them.
- When talking with someone who has a disability, speak directly to that person rather than through a companion who may be with them.
- Be considerate of the extra time it may take for a person with a disability to get things done or said. Let the person set the pace in walking and talking.
- Relax. Don't be embarrassed if you happen to use accepted, common expressions, such as "See you later" or "Got to be running along" that seem to relate to the person's disability.
People with Vision Disabilities
- Any aid or equipment a person may use, such as a wheelchair, guide cane, walker, crutch or assistance animal is part of that person's personal space. Do not touch, push, pull or otherwise physically interact with an individual's body or equipment unless requested to do so. If it is necessary to move a person's mobility device, never do so without asking first.
- Always ask before you move a person in a wheelchair, out of courtesy, but also to prevent disturbing the person's balance.
- If a person transfers from a wheelchair to an examining table, bathtub, toilet, ect., be sure not to move the chair beyond easy reach. If the person uses some other aid, such as crutches or a walker, make sure they remain accessible to the patient.
- Always make sure the wheelchair is locked before helping a person transfer.
- When conversing at length with a person in a wheelchair, sit or place yourself at that person's eye level, but do not kneel.
- Don't patronize people who use wheelchairs by patting them on the head.
People with Hearing Disabilities
- When you offer to assist someone with a vision impairment, allow the person to take your arm. This will help you guide rather than propel or lead them.
- When greeting a person with a severe loss of vision, always identify yourself and others who may be with you. Speak in a normal tone of voice, indicate when you move from one place to another, and let it be known when the conversation is at an end.
People with Speech Disabilities
- To get the attention of a person who has a hearing disability, tap the person on the shoulder or wave your hand.
- Look directly at the person and speak clearly, slowly and expressively to establish if the person can read your lips. Not all persons with hearing impairments can lip read. Those who can rely on facial expressions and other body language to help in understanding.
- Show consideration by placing yourself facing the light source and keeping your hands and food away from your mouth when speaking. Keep mustaches well-trimmed.
- While shouting won't help, written notes can.
People with Cognitive Disabilities
- Give whole, unhurried attention when you're talking to a person who has difficulty speaking. Keep your manner encouraging rather than correcting, be patient rather than speak for the person. When necessary, ask short questions that require short answers or a nod or shake of the head.
- Never pretend to understand if you are having difficulty doing so. Repeat what you understand. The person's reaction will assist you and guide you to understanding.
- Take the time necessary to assure clear understanding. Use simpler words and add gestures while you talk. Use precise language and try to employ words that relate to things you both can see. You may need to write down information or draw a simple pciture.
- Be prepared to give the person the same information more than once in different ways.
Creating more universally usable health care environments and services benefits all your customers, including those patients with disabilities. Knowledge of existing codes and standards serves as a starting point in meeting accessibility guidelines. Going beyond accessibility requires a partnership with your patients with disabilities. By creating a team, you can meet the intent of the law and foster an atmosphere that welcomes everyone into your health care facility.
For More Information:
To obtain copies of the ADA Standards for Accessible Design (ADASAD) and the Title II and Title III Technical Assistance Manuals, contact the Disability and Business Technical Assistance Center (DBTAC) at 1-800-949-4232 V/TTY (this number will automatically route your call to the DBTAC in your region) or the U.S. Department of Justice at: Public Access Section, Civil Rights Division, U.S. Department of Justice, PO Box 66738, Washington, DC 20035-9998, 800-514-0301: 800-514-0383 (TTY)
For Design or Product Information, Contact: The Center for Universal Design, School of Design, North Carolina State University, Campus Box 8613, Raleigh, NC 27695-8613, 1-800-647-6777 (V/TTY) (919) 515-3023 (fax), Website http://www.design.ncsu.edu/cud
For a more detailed discussion of the ADA requirements for medical care facilities, you may order the 17 page technical assistance document titled Medical Care Facilities from the Center for Universal Design.
This project to improve accessibility of health care environments and to promote the health, wellness, and inclusion for persons with disabilities was a collaborative effort of the NC Office on Disability and Health and The Center for Universal Design.
The Center for Universal Design
School of Design
North Carolina State University
Campus Box 8613
Raleigh, NC 27695-8613
(919) 515-3023 (fax)
The North Carolina Office on Disability and Health
Frank Porter Graham Center
The University of North Carolina at Chapel Hill
Campus Box 8185
Chapel Hill, NC 27599-8185
(919) 966-0862 (fax)
Website - http://www.fpg.unc.edu/~ncodh
The North Carolina Office on Disability and Health
Division of Women's and Children's Health
NC Department of Health and Human Services
P.O. Box 29597
Raleigh, NC 28626-0597
(919) 715-3049 (fax)
Author - Ronald L. Mace, FAIA
Editors - Woodward Communications, NC Advisory Committee on Disability and Health, Leslie Young
Graphic Design - Robert Rock
Illustrations - Rex Pace
Funding: This publication was made possible by a grant from the Centers for Disease Control and Prevention, National Center for Environmental Health, and the Office on Disability and Health (U59/CCU403365-10).