A growing body of research on health disparities among ethnic groups is making it increasingly clear that being a member of a minority group in the United States can be a barrier to health care. The inability to speak English has been empirically associated with less care seeking and limited access. Now more than ever, the tide of US health care has to be turned to work more effectively with limited English proficient (LEP) populations. In the medical world, language barriers create problems for both patients and providers.
For patients, language and communication influence how and if LEP patients access and experience health care. Because of the language barrier, LEP patients often encounter basic problems such as a lack of awareness of existing services and how to access them. LEP patients also often have the inability to communicate adequately with health care support staff and providers. As language service providers (LSPs), we need to be on the front lines with specialized medical translation and interpreting services.
Though language barriers have long been a concern for health professionals and patients in this country, the debate over what qualifies as adequate supplementary language services for LEP patients and how to pay for these services has been especially heated in recent years. As health care systems aim to provide enhanced service to their patients, meet federal standards and become assimilated to their diverse communities, they are becoming more proactive about their need for language services (see sidebar on page 30).
With the current administration taking a harder look at institutions that do not meet federal regulations and because of the increase of the LEP populations being served, health care systems are looking at the need to budget for language services, though this is just one area of concern. Understanding what it entails to comply with federal regulations and providing the most effective communication possible to patients, both verbally and written, are also high on the list of health care facility concerns. As a matter of fact, under the Patient Protection and Affordable Care Act of 2010, the Centers for Medicare and Medicaid Services has a program designed to provide incentive payments to hospitals that meet set performance standards for selected quality measures, including communication about medicine and communication with doctors and nurses.
LSPs tapping into the opportunity
One of the most important parts of providing adequate health care is the exchange of information between patient and caregiver. Without clear communication, it is difficult and can even be dangerous to treat a patient. For LEP patients as well as providers, the presence of a trained medical interpreter can dramatically change the effectiveness of care communication.
Until recently, there has been no national standard by which to evaluate medical interpreters. Even national requirements on the part of hospital accreditors were lax. In January 2010, however, the Joint Commission released new standards concerning patient-provider communication that went into effect in early 2011. One standard specifically addresses qualifications for language interpreters and translators. This push toward setting standards has opened up an opportunity for LSPs to enter into the medical interpreting space rather than medical staff relying on family interpreters.
There have been a few highly publicized incidents of medical interpretation gone wrong, one being the 1980 case of Willie Ramirez, a Spanish-speaking teenager from southern Florida. Ramirez reported feeling dizzy and having a headache, the result of an intracerebellar hemorrhage, to doctors at an area hospital. However, because among other reasons he and his family insisted he was intoxicado, his original ailment was diagnosed as an intentional drug overdose. The word intoxicado in Spanish, though, can mean feeling dizzy or nauseated. Ramirez became a quadriplegic as the result of the misdiagnosis. This case is often referred to as one example of the need to have qualified medical interpreters available in the hospital. Many hospitals subscribe to a telephone interpreting service because of the many languages for which they may have to be responsible. Similarly, because of the lack of one national standard, many facilities had to rely on bilingual staff members who could serve as an interpreter in addition to their normal duties — and many still do. However, now with legislation and culture shifts, LSPs have a prime opportunity to position themselves as a partner in medical interpreting.
Interpreters want to be acknowledged for the great work they do, while clients are seeking qualified trained interpreters in an agency that didn’t cut corners. Taking this stance when starting a medical interpreting service line is important. Knowing that you are dealing with critical medical information and patient interactions brings a level of intensity that isn’t always present in other types of interpreting activities.
The most important component for successfully expanding into medical interpreting is that the current interpreter pool be trained in the field of medical interpreting. You may think that interpreters who provide services to other industries may be suited for medical interpreting, but health care has its own set of standards an interpreter has to follow.
What types of considerations should be made when an LSP is thinking about starting a medical interpreting service line? While there is no mandatory certification in the medical interpreting field, interpreters should be required to be tested for oral proficiency prior to entering a medical interpreting training. Specific medical interpreting training should follow where they are taught the importance of following the standards of practice, what role they should play in patient care and the importance of Health Insurance Portablility and Accountability Act (HIPAA) and confidentiality.
Taking a chance on sending in an interpreter with no formal training will almost undoubtedly result in losing that client. LSPs must consider that health care interpreting is highly competitive, and they may have to also be competitive in their pricing. Another factor to consider when expanding into medical interpreting services is the recommended use of a scheduling database to cut back on the number of calls that one can receive. Instead, all appointments are entered, assigned and seen by your clients. This will reduce possible errors in time, date or language, which result in the patient not having an interpreter.
Becoming a vendor for any hospital or health care facility requires the LSP to understand what Title VI means and how you can help with compliance. Simplified, Title VI is part of comprehensive US law intended to end discrimination based on race, color, religion or national origin. It assures nondiscrimination in the distribution of funds under federally assisted programs. President Clinton’s Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency” issued in 2000, attempted to clarify and strengthen the language access implications of Title VI.
We are frequently asked how to position an agency to appeal to hospitals as an interpreting vendor. There are a few points that we have learned over the years that will help any agency start making good contacts at hospitals.
A challenge in selling medical interpreting services is that there isn’t a single common point of contact to sell to. Each hospital or health care facility structure is different, and interpreting services are housed within different offices. The process for making a contact can at times be difficult. Interpreting services can be housed in the social work department, nursing administration, a volunteer department or the patient representative office. Making calls directly to the hospital very rarely has resulted in getting to the right person. What does? A bit of creativity.
A tactic that I have taken is going directly to and walking through the hospital, taking notes on areas that need signage and asking staff what steps are taken to access an interpreter. It gives me the proper information to establish a need. I begin talking to staff members who have direct patient interaction (nurses, receptionists) and forward my information from there. The buy-in for interpreting services really comes from those working with patients and not always management.
Once you have this outline established, there is also typically a need for some education on the part of the LSP. Here are a few tips and insights that will help you engage with the right points that are important to the hospital or health care facility. As a qualified medical interpreting vendor, you will be able to provide assistance in implementing the new Joint Commission standards; be available to assess staff or provide training on how to work with interpreters; provide them with more than one option for interpreter services, such as telephone, on-site or video remote interpreting; and offer opportunities to check your references against other facilities you have worked with.
Qualifying and partnering
Whether the health care system has in-house medical interpreters or contracted language professionals, they all should meet a strict list of criteria prior to being considered as a qualified medical interpreter. While starting a training program might not be high on an LSP’s list, what should be is seeking qualified interpreters who are proficient in their language pair both in writing and orally. This means they should have passed an oral and written assessment, attended training involving topics such as ethics, HIPAA, OSHA, Title VI, terminology relevant to the industry, role play, field experience and professional development.
In order to successfully interact with patients and favorably represent your agency, interpreters should also clearly understand expectations and standards. Interpreters must always obey the code of confidentiality. Sharing information with others is a HIPAA violation and causes an agency or hospital to be penalized. Interpreters must always be prepared for their assignments. Before going to an assignment, a good interpreter will research the information and terminology.
Where interpreters position themselves is important, in that the relationship is always between the patient and service provider. An interpreter who remains on the side of the provider can make the patient feel helpless and alone. Interpreters must be conduits of information only and refrain from taking on the role of a social worker, friend or health professional. They facilitate communication, and when an interpreter feels too close to the patient, it may be in the best interest of the patient that the interpreter no longer serves as the person interpreting. There are times when an interpreter is a cultural broker or clarifier, sometimes even an advocate. However, interpreters should proceed with caution when taking on the role of an advocate since it can do more harm than good. Interpreters who participate in medical interpreter training and clearly understand the importance of their role as a conduit, their positioning and the need for confidentiality will truly develop in-
to professionals and will be recognized as such.
What makes a successful health care facility and LSP relationship? Years of fine-tuning the process has given a clear answer: partnership and education. Simply offering a medical interpreting service won’t necessarily yield success. Many staff members have never worked with professional interpreters or an outside language service vendor. Educating them and developing protocol systems that will work within the confines of their facility will make for a much more successful partnership and offer a value add to working with your agency.
The earlier a medical interpreter is involved in an LEP patient’s care, the better. Ideally, a patient needing an interpreter will be identified upon registration, and an interpreter will be scheduled for all the appointments. If that doesn’t happen, however, encourage clinicians to call an interpreter as soon as they realize the need. It’s worth waiting for the interpreter to arrive, since the encounter will probably go more smoothly and quickly with an interpreter present.
Take time to prepare. It’s useful for the interpreter and clinician to have a short preconference before seeing a patient to clarify the goals of the appointment and what will occur. For example, medical staff will often begin to converse directly with the interpreters. As part of the education process, LSPs/interpreters should encourage clinicians to speak directly to the patient, not the interpreter.
Medical interpreting should stylistically be short and simple. Speaking in short sentences allows for complete and accurate interpretation. Even though interpreters are trained to develop a good memory, they cannot keep up with everything when a provider keeps on talking. Again, there will be some education on the process needed on the end of the provider. Providers should also avoid using complicated medical terminology. Although trained medical interpreters can interpret that information, technical jargon can be confusing. Providers shouldn’t be surprised if an interpreter asks them to slow down or repeat critical information, such as medication names and doses. Knowing the personalities of your interpreters and needs of the provider will in turn guide an LSP to select the best match for both. It is important to stay in touch with the provider to see how services are going and what can be tweaked for improvement. Knowing the background of your interpreters will also help make matches based on experience. We match interpreters to our clients in terms of their seniority, capabilities and interpreting experience.
We have health care facilities that often request coverage. This entails the interpreter carrying a pager and seeing multiple patients throughout the day. When these calls are received, we do not just send anyone. We pull our most senior interpreter who is able to handle this kind of volume, able to run from one end of the hospital to the other and work without a break. Our clients really like this and know that we won’t shortchange them.
Matching specialties is also very important. For example, we have one interpreter who has worked often in labor and delivery. The interpreter has been present during many deliveries where the babies were stillborn. That same interpreter is requested to return for the memorial service that the hospital holds for parents of babies that have died. This interpreter knows how to handle an extremely sensitive situation, and we make sure to provide this interpreter’s services for those instances.
Not only should an LSP provide quality interpreting services, it should also consider what other ancillary services it can provide. For example, I have trained professional nurses on how to better understand the needs of other ethnic groups. Many health professionals were struggling with certain beliefs, values and taboos that came with understanding how to manage disease — for example, diabetes within the Hispanic community, how to limit food intake during the holidays and understanding why in some cultures you couldn’t speak directly to the patient, but to the spouse.
The bottom line is that medical interpreting is more than just translating spoken words from one language to another. It involves conveying messages, cultural nuances and promoting understanding between the medical staff and patients from different backgrounds. It is one of the most unique and rewarding types of interpreting services. There are challenges in offering medical interpreting services, but with the makeup of our population becoming increasingly multilingual, the demand for these services will continue to grow.