Lines of Communication: Linguistic Competence & Interpreter Services in Healthcare Settings

1. Lines of Communication: Linguistic Competence & Interpreter Services in Healthcare Settings JOHANNIE RESTO, BSB MANAGER OF INTERPRETER SERVICES VANDERBILT MEDICAL CENTER

2. Covered Topics • Why the Provision of Interpreter Services ? • Compliance Requirements • Medical Interpreting Overview

3. OBJECTIVES • To increase awareness of the Legal Mandates that guide institutions as it relates to patients who have limited English proficiency • Learn the benefits of Interpreter Services • Learn techniques that help manage the flow of communication when an interpreter is present.

4. LIMITED ENGLISH PROFICIENCY (LEP) A LEP individual is a person who is unable to speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers and social service agencies.

5. The Top 15 Languages at VUMC FY 2010 • Spanish • Arabic • Somali • Kurdish • Chinese • Vietnamese • Russian • Persian (Farsi) • Korean • Japanese • Burmese • Laotian • Amharic • Sign Language • Bosnian

9. WHY SHOULD WE PROVIDE INTERPRETER SERVICES ?

10. Interpreter Services • Patient Safety • Quality Healthcare • Compliance Requirements

11. Providing Quality Healthcare • Communicating effectively with patients in their language • Clear understanding of symptoms • Ability to communicate their diagnosis, prognosis, explain tests, procedures, discharge instructions, how to take their medicines, follow-up appointments • Recognizing different cultural and religious factors that often impede our ability to perform examinations, recommend treatments, accurate diagnosis, prognosis, and treatment plan • Understanding financial issues

12. COMPLIANCE REQUIREMENTS Under Title VI of the Civil Rights Act of 1964 the denial or delay of medical care because of language barriers is discrimination. Any medical facility that receives Medicaid or Medicare must provide language assistance to patients with LEP and take steps to ensurethat persons have meaningful access to the health services that they provide.

13. Title VI of the Civil Rights Act of 1964 “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”42 U.S.C. Section 2000d

14. Joint Commission on Accreditation of Healthcare Organizations • Requires use of medical interpreters with proven competency (The 1997 Accreditation Manual for Hospitals. SectionR1.1.4. The 2001 Comprehensive Accreditation Manual for Hospitals. Standard R1.1.2.) • Train staff to recognize and respond appropriately to patients with language needs.

15. National Standards on Culturally and Linguistically Appropriate Services (CLAS) Issued in March 2001 The national standards issued by the U.S. Department of Health and Human Services’ (HHS) Office of Minority Health (OMH) respond to the need to ensure that all people entering the health care system receive equitable and effective treatment in a culturally and linguistically appropriate manner.

16. CULTURALLY LINGUISTIC APPROPRIATE STANDARDS (CLAS) Language Access Services (Standards 4-7)

17. Standard 4Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient with limited English proficiency at all points of contact, in a timely manner during all hours of operation. • Standard 5 Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

18. Standard 6 Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. • Family and friends should not be used to provide interpretation services • Bilingual providers must demonstrate language proficiency, and adequate knowledge of technical terminology “relevant to the encounter”. • Crash courses or “survival language courses” pose a threat, because clinicians overestimate their fluency. • Minors should NEVER be used.

19. Standard 7 Translated Materials Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

20. CASE Inadequate communication can have tragic consequences

21. Case 1 A high profile case in Florida in 1984 were Spanish-speaking 18-year-old had stumbled into his girlfriend’s home, told her he was “intoxicado,” and collapsed.

22. When the girlfriend and her mother repeated the term, the non-Spanish-speaking paramedics took it to mean “intoxicated”; the intended meaning was “nauseated.”

23. After more than 36 hours in the hospital being worked up for a drug overdose, the comatose patient was re-evaluated and given a diagnosis of intra-cerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery.

24. Conclusion Misinterpretation of a single word led to a patient’s delayed care and preventable quadriplegia. The hospital ended up paying a $71 million malpractice settlement because of one word that was misinterpreted in the Emergency department, causing permanent damage to the patient. References: The New England Journal of Medicine; Language Barriers to Health Care in the US by Glen Flores,MD. Volume355:229-231 July 20, 2006 number 3 (Harsham.P. - A misinterpreted word worth $71 million. Med Econ 1984; June:289-292.)

25. CASE 2 An untrained bilingual staff, misinterpreted for a nurse practitioner, told the mother of a seven-year-old girl with otitis media to put (oral) amoxicillin “in the ears”.

26. Case 3 A Spanish-speaking woman told a resident that her two-year old had “hit herself” when she fell off her tricycle; the resident misinterpreted two words, understood the fracture to have resulted from abuse, and contacted the Dept. of Social Services (DSS). DSS sent a worker who, without an interpreter present had the mother sign over custody of her two children. Clearly, Catastrophes can and do result from such miscommunication. Reference- The New England Journal of Medicine; Language Barriers to Health Care in the US by Glen Flores,MD. Volume355:229-231 July 20, 2006 number 3 http://content.nejm.org/cgi/content/full/355/3/229

27. Benefits of Interpreter Services in Healthcare • Patient Safety • Increase the Patient Loyalty for the Hospital • Patient Impact and Satisfaction • Compliance • Lowers Risk to the Hospital • Decrease Hospital stays • Less complications • Misuse of expensive Emergency Services • Less unpaid bills due to proper communication and handling of the insurance/financial status of the customer/patient

28. Medical Interpreting

29. What is the difference between Interpreting and Translating?

30. Interpreting To render messages orally, from one language into another. Interpretersare theVOICE!!

31. Translating To render written text from one language to another.

32. What is the Basic purpose of the Medical Interpreter?

33. Basic purpose of the medical interpreter Is to facilitate understanding in communication between people who are speaking different languages.

34. Medical Interpreting

35. Roles of the Medical Interpreter ADVOCATE CULTURAL BROKER CLARIFIER CONDUIT Interpretersare theVOICE!!

36. Tips for Effectively Working with an Interpreter • Brief the interpreter before entering the room. • Position yourself to maintain eye contact with the patient. • Address the patient, not the interpreter using “I” and “you”, not “he or she”. • Remember that everything you say will be interpreted. • Avoid highly technical jargon and acronyms. • Check for understanding.

37. Pause often to allow the interpreter to accurately convey your message • Make short and precise questions or statements • Avoid side conversations • Focus your attention on the patient or family not the interpreter • Avoid asking the interpreter his/her opinion

38. AVAILABLE RESOURCES VANDERBILT UNIVERSITY MEDICAL CENTER 15 full-time interpreters (13 Spanish, 2 Arabic) 35 plus temporary interpreters (Spanish, Arabic, Bosnian, Burmese, Chinese, Kurdish, Russian, Somali, Swahili, Farsi, Japanese, Portuguese, Vietnamese, Amharic, Urdu, Harraric) Interpreters are assessed, trained, follow National Standards for Healthcare interpreters and Code of Ethics Telephonic Interpreter line 24/7 “OPI” Staff calls 1-877-746-4674 Patient calls 1-866-675-2040 (If pt needs to call VUMC) After hours (message center) has a list of the VTS temporary interpreters 2-7378

39. After hours Spanish interpreter available Monday thru Friday from 4:30pm to 8:00am . Saturday and Sunday 24 hour coverage. Please page 835-0507 and leave numeric message • Services for the Hard of Hearing and the Deaf (615-248-8828) staff calls directly • TTY/TDD phones available for the deaf and hard of hearing . TTY stands for telephone typewriter, teletypewriter or text, TDD stands for Telecommunications Device for the Deaf. TTY/TDD stands for a group of telecommunication devices that make it easier for deaf and/or mute people to talk over telephone lines. TDDY phones for the Hard of Hearing. • Signage assuring the patients that they are entitled to interpreters at no cost `

40. On-site interpreters 2-SERVE (2-7378) • Interpretive Services Policy Communications OP 10-50.01 (will be updated) • Documents are translated by professional translators e-mail documents to: http://www.vanderbilthealth.com/main/23115 • NEVER use Babble fish or any other translation system via the Internet • Interpreter Services website address: www.mc.vanderbilt.edu/interpreter http://www.vanderbiltchildrens.org/interpreter

41. Questions

42. THANK YOU! INTERPRETER SERVICES DEPARTMENT johannie.resto@vanderbilt.edu Office- 615-936-0837

43. Articles of Interest/References National Council on Interpreting in Health Care (NCIHC) http://www.ncihc.org/ Common cross-cultural communication challengeshttp://www.wwcd.org/action/ampu/crosscult.html#COMMUN OCR list of “vital” Documents. www.hhs.gov/ocr/lep Office of Minority Health CLAS standards Final Report http://www.omhrc.gov/assets/pdf/checked/finalreport.pdf Addressing Language Barriers in Health Care: What’s at Stake, by Robert Wood Johnson Foundation . March 2007

44. Navigating Language Barriers under difficult circumstances Annals of Internal Medicine- American College of Physicians by Yael Schenker, MC,;Bernard Lo, MD; Katharine M. Ettinger, JD; and Alicia Fernandez, MD Language Barriers to Health Care in the United States by Glenn Flores, MD.