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More than RampsA Guide to Improving Health Care Quality and Access for People with Disabilities$

Lisa I. Iezzoni and Bonnie L. O'Day

Print publication date: 2006

Print ISBN-13: 9780195172768

Published to British Academy Scholarship Online: September 2009

DOI: 10.1093/acprof:oso/9780195172768.001.0001

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(p.286) Appendix 3 Suggestions for Improving Accessibility of Health Care Services

(p.286) Appendix 3 Suggestions for Improving Accessibility of Health Care Services

More than Ramps
Oxford University Press

Meeting standards of the Americans with Disabilities Act (ADA) provides only a starting point for ensuring accessibility of health care services. Many physical settings and practices that comply with ADA regulations are nevertheless difficult and uncomfortable for certain persons with disabilities. In addition, the ADA does not address the interpersonal interactions that form the heart of many health care encounters. The persons we interviewed offered many suggestions for making health care services more accessible and improving patient-clinician communication. This appendix lists various recommendations from the interviewees, organized into broad categories. Clinicians and health care managers could consider implementing these ideas within their own health care delivery settings. Persons with disabilities could use these recommendations to help identify clinicians and health care providers that might be more “user friendly” and accessible. Administrators and policy-makers could use these recommendations to guide evaluations of whether health care settings are not only accessible but also comfortable and welcoming places for persons with disabilities. This list, however, is not exhaustive, and implementing some suggestions may prove infeasible in certain settings.

In many ways, these recommendations distill down to three overarching messages:

  1. 1. Never make any assumptions about the abilities, preferences, expectations, or desires of persons with disabilities.

  2. 2. Instead, just ask them—for example, about how clinic staff can best assist them and about what they prefer and expect.

  3. 3. Then, to the extent possible, respect and comply with their expressed preferences.

Following these three precepts is a clear road map toward achieving accessible and patient-centered care. Optimally, as clinicians and health care providers develop new facilities and practice environments, they should (p.287) involve persons with disabilities from their communities. Designers should consider the universe of individuals—with and without disabilities, young and old—who might someday use their settings and services.

Basic Training and Organizational Policies

  • Train all office staff, including clinicians, about professional, ethical, and legal obligations relating to disability. Repeat this training periodically.

  • Emphasize the need to ensure effective communication during all interactions with all patients.

  • Make clear that the call for treating persons with disabilities equally, with respect and dignity, comes from top leadership of the organization. Leadership should systematically assess physical and communication access within their health care delivery setting to identify needs for new equipment, renovations, staff training, and other changes. They should strive to implement required modifications, monitoring progress toward these goals.

  • Identify an individual to oversee the full range of disability-related issues, not only for patients but also for employees.

  • Establish procedures for registering complaints that maximize privacy for all parties but are expeditious and result in practical and productive solutions to identified problems.

  • Develop and practice procedures for evacuating the facility in the case of emergency, specifically considering needs of persons with disabilities. Consider purchasing equipment to assist evacuations, such as lightweight frames for carrying wheelchair users safely down stairs.

  • Train staff and administrators about the illegality of charging patients for specific accommodations, such as fees for sign language interpreters. Investigate potential federal tax credits and deductions for providing disability-related accommodations.

  • Establish procedures for basic administrative functions. For example, determine who will work with patients to complete required paperwork and identify private settings for these interactions. Specify procedures for when and how to request sign language interpreters, as well as other specific communication or physical access accommodations.

  • Specify policies relating to e-mail and other electronic communication with patients (e.g., access to test results, online medical records). Ensure that secure Internet portals are used to maximize confidentiality and that all Web site designs meet accessibility standards.

  • (p.288)
  • Survey patients, including persons with disabilities (using accessible survey formats), about their experiences with care, and modify practices and procedures to rectify problems.

Communicating with Patients

  • Always introduce yourself to persons when entering rooms. During encounters, introduce all other persons who newly enter the room.

  • Look at persons when speaking to them. Communicate directly with patients, not family members, friends, or assistants who might accompany them.

  • When using a sign language interpreter to facilitate communication, look at and speak to the patient, not the interpreter.

  • Always speak clearly, at usual volume and a reasonable speed.

  • Ask patients how best to communicate with them. After checking that patients agree, inform all clinicians and staff who interact with patients of these preferences through prominently placed information in medical charts and/or other procedures.

  • Make appropriate efforts to comply with patients' preferred communication approach.

  • Periodically check with patients to see if communication preferences have changed.

  • Ask patients how best to attract their attention or assist them with movement or positioning during examinations and with moving in and around the office. Inform all clinicians and staff who interact with patients of their preferences.

  • For established patients, plan ahead to ensure required communication accommodation (e.g., sign language interpreter). Stay on schedule, so interpreters do not leave before visit finishes.

  • Ensure that office staff communicates discreetly with patients in public settings (e.g., do not raise voice).

  • In waiting rooms, come up to patients who are deaf or hard of hearing to notify them when their appointment time comes.

  • Describe all planned physical maneuvers, and inform patients immediately prior to touching.

  • Periodically ask patients about effectiveness of communication; request suggestions to rectify unsatisfactory situations.

  • Periodically ask patients to summarize their understanding of what has been said, particularly when conveying important technical information, to identify and correct miscommunications.

(p.289) Accessible Information and Communication Methods

  • Prepare easy-to-read written instructions, including in large-print and braille formats, about what to do before clinician arrives in examining room (e.g., which clothes to remove and why).

  • Prepare easy-to-read written instructions, including in large-print and braille formats, about examining room or testing procedures. Whenever possible, use pictures or diagrams.

  • Consider purchasing assistive listening devices to accommodate communication with persons who are hard of hearing (especially in practices with large numbers of elderly patients).

  • Acquire and learn how to use a teletypewriter (TTY). Become familiar with telephone relay services.

  • Place public TTY pay phones near specific locations (e.g., hospital waiting rooms, recovery rooms, emergency rooms, information desks) where public pay phones are available.

  • Provide easy access to a chair for TTY use, so that persons do not need to bend over while typing on the TTY.

  • Install knock sensors (small battery-powered units that attach to the inside of doors and flash a light when someone knocks—roughly $35) to examination and other room doors to alert patients who are deaf or hard of hearing when persons are outside and about to enter.

  • Review automated telephone menu systems, considering alternatives for persons with sensory disabilities (e.g., e-mail, facsimile). Ensure that callers have a ready option to speak directly to a person, such as by dialing zero.

  • In radiology units, install colored lights to signal when patients must take certain actions, such as holding their breath or resuming normal breathing.

  • In waiting rooms, use vibrating pagers or other non-visual, non-auditory means to inform patients when their appointment time comes.

  • Ensure that videos or DVDs containing educational material are captioned for persons with hearing impairments and audio-described for persons who cannot see the images.

  • Consider communicating appointment times, reminders, and certain clinical information by e-mail through a secure Internet portal to patients who indicate they have access to the Internet.

Clinical and Technical Communication

  • Focus first on the patient's chief complaint, not on their sensory or physical impairment.

  • (p.290)
  • Assume that patients have detailed knowledge of their sensory or physical impairment. Sometimes this knowledge is highly technical. At a minimum, most persons know intimately the implications of their impairments for daily bodily functioning. Therefore, ask patients relevant questions and listen to and respect their responses (e.g., about pain, risks of certain physical maneuvers).

  • Remain vigilant for risks of medical errors or iatrogenic injuries resulting from inadequate communication or inaccessible information (e.g., medication vials with labels patients cannot read, instructions given in inaccessible formats). Attempt to anticipate and prevent such situations.

  • Prepare pictures or diagrams depicting tests or procedures; have books with relevant pictures available for more detailed discussions (e.g., concerning surgery).

  • Provide brief, easy-to-read, written instructions, including in braille and large-print formats, about what to do after visits or procedures.

  • Consider making a tape recorder and cassettes available so that persons who have difficulty reading can record verbal instructions.

  • Work collaboratively and respectfully with patients, as partners to their care. Develop plans of care and self-management that take into consideration the person's disability, preferences, values, and lifestyle.

  • Address patients' interests in screening, wellness, lifestyle modification, and other services oriented toward maximizing overall health and quality of life.

  • Consider offering lists of appropriate Web sites that provide information about self-management, improving overall health, and specific diseases, disorders, and disabilities.

Physical Environment, Resources, and Equipment

Specific attributes and access issues vary widely depending on the nature of the health care facility. Many of the suggestions below might apply to most settings, although small private physicians' offices obviously differ in terms of their size and resources from large, multispecialty practices in academic centers.

Cross-Cutting Issues

  • Physical environment meets basic safety standards (e.g., visual and auditory signals for fire emergency).

  • (p.291)
  • Lighting is non-glare, uses warm tones when possible.

  • Provide bright task lighting for areas where patients complete forms or read documents.

  • Avoid backlighting in examination rooms or settings where clinicians communicate extensively with persons who are deaf or hard of hearing.

  • Minimize background noise, such as canned music.

  • Use baffling materials on walls to absorb ambient noise.

  • Flooring should minimize glare and attenuate sounds, in addition to being durable, easy to clean, and reducing risks of slips and falls. Vinyl flooring is generally preferable to ceramic tiles because it is softer and has higher friction ratings.

  • Carpeting is unpadded and has a short pile height, thus minimizing the force required to propel wheelchairs.

  • Fix any loose seams and curled edges of carpeting, vinyl tiles, linoleum, or other flooring.

  • Avoid flooring with broad stripes, large geometric designs, or wavy patterns.

  • Label all doorways and passages using clearly visible and easily understood signage, including in raised print and braille.


  • Accessible parking near entrance, including wide spaces to allow vans with automatic lifts or ramps on their sides to unload wheel-chair users.

  • Recognize problems posed by densely built urban locations that have little exterior space close by for accessible parking. May need to create alternatives, such as complementary valet parking for persons with disabilities.

  • If parking is in a multistory garage nearby, access to the health care facility should be through covered spaces with elevators kept in good order and automatic openers on all doors.

  • Smooth transitions from the loading areas and parking lot surface to sidewalks and other walkways, with detectable warnings (e.g., changes in pavement surface to cue persons with visual disabilities) at curbless crosswalks that cross vehicular traffic.

  • Covered entryways to protect persons from inclement weather.

  • Smooth, level entry into building, without steps or steep ramps.

  • Automatic door opener located so the door does not swing into persons immediately after they push the opener. When automatic revolving doors are present, they should have an easily accessible button to slow down their speed. A regular door, preferably with (p.292) automatic opener, should be available for persons who cannot use revolving doors.

  • Lever handles for doors requiring manual entry.

Waiting Rooms

  • Understand purpose of waiting room, patient volumes, and visit lengths. For instance, in busy emergency rooms, persons without immediately life-threatening conditions could wait for hours; they may nevertheless feel ill, need spaces to consult triage staff privately and expeditiously, and require places for anxious relatives or friends. Waiting areas outside of surgical suites, where visitors await news about loved ones, may demand quieter, contemplative settings, with private areas for conversations with clinicians and telephone calls with family members. Outpatient primary care practices may strive for short waits for patients who are generally not acutely ill but may need privacy to complete routine paper-work.

  • Automatic opener for door, positioned so that the door will not open into persons who just pressed the button.

  • Doors should have glass windows or sidelights to see persons approaching from opposite side; lever handles.

  • Rods or hooks for hanging coats at both standing height and wheelchair height.

  • Reception area desks at standing and sitting heights; sitting height desk has knee space to accommodate wheelchair users. Free-standing chairs available for persons who cannot stand long enough to transact business but do not use wheelchairs.

  • Private spaces nearby for office staff to assist patients confidentially with required paperwork.

  • Chairs at different heights, including for children as appropriate; some chairs with armrests and some without.

  • Open spaces dispersed through waiting room but next to seating so wheelchair users can sit with other people but outside foot traffic. Passageways within seating area wide enough to accommodate wheelchairs; these open spaces and wide passages will also accommodate baby strollers and carriages.

  • Dual-height water fountains for standing and seated users; refreshment counters accessible to wheelchair users, with knee space under table.

  • Adequate lighting for reading.

  • Racks with informational brochures, magazines, and other reading materials within easy reach; offer materials in large-print format.

  • (p.293)
  • Television controls, if any, easily reachable, with closed captioning; television volume not too loud.


  • Doors with lever handles and glass sidelights; automatic door opener optimal.

  • Minimize height of threshold; having no threshold is best.

  • If there is a second door immediately beyond outside door (e.g., to protect privacy), ensure wheelchair users have enough room to maneuver and to open inner door. If automatic door opener is installed (optimal), it should open both doors.

  • Nonslip flooring; if ceramic tiles, use small-sized tiles to minimize likelihood of slipping.

  • Wheelchair-accessible toilet door should open out, with handle and lock devices that are easy to grasp and operate.

  • Grab bars on either side of toilet, with adequate turning space within toilet stall.

  • Toilet should be slightly higher than standard height, making it easier for persons who use their legs to stand but still allowing easy transfer from wheelchair. Installing lifts to position persons with very limited mobility is optimal but requires larger space and careful planning.

  • Position toilet tissue and bins for sanitary product disposal within easy reach of person seated on toilet.

  • Tilt mirror over sink slightly forward to reflect wheelchair users.

  • Sink basin should come to edge of counter. Use lever rather than turn faucet handles. If water flow is operated by an electronic sensor device, make sure persons in wheelchairs can easily trigger sensor.

  • Soap dispenser and paper towels easily accessible to persons in wheelchairs.

  • Avoid having hot air blower as the only way to dry hands. Some people may find it difficult to stand in front of the blower long enough to dry hands; furthermore, this device can pose problems for some walker and cane users.

Examination Rooms

See relevant suggestions above.

  • Automatically adjustable examination table with ample space for wheelchair maneuverability; if not, have appropriate lift devices, with trained staff to operate them.

  • Wheelchair-accessible scale readily available within clinic.

(p.294) Specialized Facilities and Services

See relevant suggestions above.

  • Surgery units, recovery rooms, labor and delivery suites, emergency departments, radiology suites, and other specialized units should establish specific protocols for effective communication during all phases of care.

  • When purchasing new equipment, search for models that are accessible, maximizing independence for patients and minimizing injury risks to staff (e.g., from transferring patients).

  • Review policies about removing and returning hearing aids to maximize patients (safety and comfort; discuss policies and safeguards with patient before procedures.

  • Consider using colored lights to signal when patients must take certain actions during radiology studies (see above).

Transportation Awareness

  • Have listing of accessible bus and transportation routes that serve facility.

  • Ensure that office staff can give accurate directions using non-visual cues from the bus or subway stop to the health care facility.

  • Be aware if patients are using paratransit services; ensure they are finished with their visit by the paratransit pick-up time.

Other Recommendations

  • Become familiar with various clinical disciplines, such as physiatry (physicians who specialize in physical medicine and rehabilitation) and physical and occupational therapy, that provide care to persons with certain disabilities. Learn about when to refer patients to these other specialists.

  • Become familiar with broad classes of assistive technologies used by persons with disabilities, and learn about where to refer patients to obtain more specific information and, when relevant, about writing prescriptions for this equipment. Learn more about preparing effective “medical necessity” documentation justifying health insurance purchases of necessary assistive technologies.

  • Become aware of devices that aid persons with physical and sensory disabilities with self-management tasks, such as “talking” glucose monitoring equipment and thermometers and adapted pill (p.295) minders. Know where to refer patients to get more information.

  • Learn about local resources, such as sign language interpreters specifically trained for medical encounters, telephone and video relay services, and pharmacies that provide large-print and/or braille labeling and instructions for medications.

  • Identify local consumer groups of persons with disabilities that might offer peer support and consider referring certain patients to these groups.

  • Keep fresh hearing aid batteries in stock. These batteries come in a few standard sizes and will keep for several years. If patients with hearing aids lose battery power unexpectedly, providing them with a new battery can help restore their ability to communicate.

  • If state telephone carrier has a program for providing free or discounted TTY equipment, amplified telephones, alerting devices, or other equipment to qualified residents, health care office could display leaflets for the program and keep application forms and contact information to distribute to appropriate patients.