One of the challenges of providing health care interpreter services is assuring quality. Measuring language skills and interpreting ability is important to establish the competency of health care interpreters, however no commercial tests now exist to measure interpreter skills or language ability in a health context.

To fill this void, across the country, conscientious managers and health organizations have created a variety of untested tools to determine qualifications for the interpreting role. Many tools sold commercially are also not validated. With improvements, the Language and Interpreter Skills Assessment (L&ISA) piloted by Hablamos Juntos demonstration sites can meet this need. L&ISA consists of three tools developed for Connecting Worlds with funding by The California Endowment. The fourth tool developed for Hablamos Juntos, uses the same design to assess for high, medium, low competency at the intermediate Spanish level.

The first round of L&ISA pilot testing was recently completed. Demonstration sites established thirty-seven test centers, hired local test administrators to oversee testing in the region and trained two raters to score local test results. The tests were computer administered, which eliminated the need for printed test materials and maintained test security. By September 2004, 674 tests (364 language proficiency and 310 interpreter readiness) had been administered.

The data from these initial tests is still being complied and analyzed. Studies on reliability, cut-off points, what scores mean, still remain to be done if the project is to be meaningful. Additional development funding is needed to: a) implement improvements identified during the pilot phase; b) upgrade the quality of the audio and video components to create commercial-quality tools; c) strengthen test content and security by adding more task options; and d) add more languages. These efforts will hopefully demonstrate the promise of empirically based low cost publicly available language and interpreter testing.

Although the data is still being analyzed, it remains undeniable that uniform testing to determine quality is necessary. Of those tested in the demonstration sites, about 40% of Spanish health interpreters are heritage speakers who learned the language of their parents at home and have had no formal language education. Although heritage speakers often acquire native language proficiency, the language learned is based on their parents’ variety and often limited to basic conversation. Further, a person’s ability to speak the language does not ensure that they will be able to perform well in health care encounters because interpreting requires more than language ability.

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Results have been compiled from the Hablamos Juntos first phase of the symbols survey project

Signs That Work was launched in May with funding provided by the Pioneer program of The Robert Wood Johnson Foundation. The project will create a set of tested symbols that designers and health care administrators can use to create friendly facilities that can adequately accommodate those with limited English ability.

In the first of four rounds, 90 respondents were surveyed by the ten HJ grantee sites. The respondents, included men and women between the age of 18 and 65. Of the selected respondents, 19 spoke English, 19 spoke Spanish, 26 an Asian/Pacific Island language and 26 an Indo-European language.

The symbols survey tested 154 symbols for 28 referents (the terms depicted by the signs) commonly found in health signage. Overall, one third of referents have one symbol considered meaningful to the population tested, which is an extremely encouraging statistic. Symbols that receive a score of 87 or better will be considered for the new health care symbols signage system.

Symbols that received a rating of 100 were for the following referents: emergency, ambulance entrance, radiology, immunizations, OB clinic, and chapel. Referents of cancer, diabetes, and interpreter services received some of the lowest ratings, and therefore will have to be re-designed.

The results and the feedback the administrators provided regarding the implementation process will help plan for round two of the Symbols Survey Project, which is currently underway.

Once the top twenty to thirty most comprehensible symbols have been identified, the chosen symbols will then be installed and tested in pilot facilities to determine whether this form of signage is more effective than word base signage. Four health facilities, meeting project criteria, are needed to support this evaluation. Applications for pilot sites are due December 17, 2004.
Hablamos Juntos commissioned JRC Design in January 2003 to research whether symbol signs can be an effective means of enabling those who do not read English to access health services. During the summer of 2003 the design team convened to decide the top priority referents for the new signage system.

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In light of major global events over the past couple of years, the U.S. government has identified a growing need for increased multi-lingual abilities across a variety of fields. With the expansion of global business, the desire for increased national security, and the large base of limited English speakers in the country, the Senate has responded with a resolution calling 2005 the “Year of Languages”.

The resolution specifically “requests that the President issue a proclamation calling upon the people of the United States to encourage and support initiatives to promote and expand the study of foreign languages and observe the ‘Years of Foreign Language Study’ with appropriate ceremonies, programs, and other activities.”

The primary goal is to see foreign language studies more integrated in all levels of education, businesses, and government programs. The Senate identified multiple reasons why there needs to be a “right here, right now” attitude about increasing Americans’ language capabilities:

• A shortfall of experts in foreign languages has seriously hampered information gathering and analysis within the American intelligence community as demonstrated by the 2000 Cox Commission;
• According to the Centers for International Business Education and Research program, foreign language study provides the ability to both gain a comprehensive understanding of and interact with the cultures of United States trading partners, and thus establishes a solid foundation for successful economic relationships; and
• Report 107-592 of the Permanent Select Committee on Intelligence of the House of Representatives concludes that American multinational corporations and nongovernmental organizations do not have the people with the foreign language abilities and cultural exposure that are needed.

Organizations such as the American Council on Teaching Foreign Languages (ACTFL) and the National Language Conference (NLC) have planned initiatives over the next year through literature, conferences, and activities to support this new language policy. Similarly, Hablamos Juntos intends to get involved with these activities as well as help promote the senate resolution.

Many of these sponsoring organizations have specifically mentioned the need for better language capabilities in governmental and non-governmental healthcare facilities. Hablamos Juntos encourages all interested parties to use this opportunity to get involved in promoting awareness about necessary changes that make the “Year of languages” important to Americans continued success in a variety of fields. Specifically, Hablamos Juntos encourages organizations to support initiatives that emphasize the need to improve the foreign language competencies of this country’s health workforce and invest in education programs that will lead to well trained interpreters and translators.

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Recognizing an organization has a problem is a good first step, but finding solutions is the mark of a good organization.

The Med, a public trauma medical center in Memphis, is committed to Performance Improvement as a way to implement practical solutions as part of day-to-day routines to achieve and sustain improvements in language services. The Regional Medical Center at Memphis is a member of a coalition of hospitals called University Medical Center Coordinating Council (UMCA), which develops performance improvement initiatives that all members can participate in. Collaboration within UMCA enables local provider to work on similar issues using the latest in evidence-based approaches from Institute for Health Improvement, another RWJF funded program.

Brenita Crawford, the chief operating officer at the Med, will tell you that their performance improvement approach will ensure limited English patients at Regional Medical Center at Memphis receive safe, timely, effective, efficient, equitable and patient-centered services. Working incrementally, The Med is using a series of measures to emphasize the importance of getting people involved every step of the way. The first objective is to improve the quality and availability of language services for Latino women in the labor and delivery departments.

One of the initial parts of the approach is to create a sense of urgency. Hospital administrators respond to pressing concerns about employee and patient satisfaction, especially if it compromises the process of delivering good healthcare.

Crawford used the results of an employee survey to show that employees experience a high rate of fear and frustration with their inability to communicate with the growing Latino patient base. They were afraid of making a mistake or having a miscommunication. One malpractice suit that stemmed from a misunderstanding could be enough evidence to prove patient safety is directly tied to communication, said Crawford.

Once people are aware, it is important to get their support. At the Med, Crawford realized she could not get everyone to jump on board at once. However, she realized if she started with some of the influential people in the organization, others would follow.

Finding these important influential people required communication and marketing. Crawford went to multiple meetings at all levels of the organization to recruit and to make others aware, from managers to CEO’s to board members.

Using multidisciplinary teams to bring about improvements health care goes back to the 1930’s. Improvement teams, typically consisting of 3 to 9 people who are directly involved in the care process, buy into the notion that real improvements often depend on the coordinated actions of many different people, none of whom can generate solutions on their own, however well-intentioned or skilled.

A quality improvement model begins with a high-level road map to show the many steps and people involved. The Med is using Rapid Cycle Improvement, an approach centered around three simple questions: “What are we trying to accomplish?” (The aim), “How will we know if a change is an improvement?” (A way to measure progress), and “What changes can we make that will result in an improvement?” (Short term goals)

To be successful, the team needed to be practical with its goals. This “guiding coalition” created short and long term goals. The short-term goals gave the rest of the hospital tangible results that help anchor overall change. Short-term goals include a restricted fund to save money for future language and culture initiatives. Over the long term, the coalition hopes to incorporate language and culture elements into the permanent Quality Improvement and Patient Safety Plans of the organization. For example, they are looking for a way to translate electronic documentation into other languages when needed.

These efforts have lead to one of the most notable successes: improved relations with the Latino community. The Med is situated in a dynamic community, and implementing culturally sensitive change was no longer a choice but a requirement. The quality initiatives the Med adopted required them to implement a series of small solutions for specific needs.

The Med has shown the ability to carry out these steps requires creating an environment conducive to consistent improvements and the support from employees to do so.

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Brief:
JRC Design, the company commissioned by Hablamos Juntos to lead the design of universal healthcare signs, had their efforts recognized in the Arizona Republic. The article discusses the company’s with Hablamos Juntos in developing the signs and the different phases of testing, as well as their ambition to have hospitals across the country adopt the signage they have created.

The link is also posted in the Media Center on the Hablamos Juntos website.

Hospitals turning to medical interpreters to avoid 'charades'

By Joann Loviglio, Associated Press Writer

Brief:
The Associated Press highlighted the Temple University Health System efforts to provide more interpreters for the surging Hispanic population in their community. The article discusses how Temple, using the grant from the Robert Wood Johnson foundation, is showing that interpreters are not a costly burden, but in fact are cost effective solutions to using family and friends as translators.

The link is also posted in the Media Center on the Hablamos Juntos website.

Hablamos Juntos (Spanish for "We Speak Together") is a unique project designed to forge connections between health care providers and the rapidly growing Latino health market. As a national program of the Robert Wood Johnson Foundation, Hablamos Juntos is investing $10 million in ten demonstration sites around the country. These sites, ranging from health plans and large hospital systems to small nonprofit community organizations, will work to improve communication between health care providers and patients and eliminate language barriers that can lead to medical errors and compromise the quality of care.

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