March 2007

Communication is essential to health care delivery. Even with a million dollar grant for each of our demonstrations, we found that improving the availability and quality interpreters, and developing useful materials for limited English proficient (LEP) patients requires much more than most health care organizations alone can deliver. This article touches on interpreters as an example of the challenges that need to be overcome before health care organizations are able to assure safe, quality health care for LEP patients. A series of special reports for 2007 will feature lessons learned from our national demonstrations and discuss implications for policy and practice as a supplement to these eUpdate.

Over the last few decades, interpreters have gained prominence as a tool for health communication and are fast becoming the standard of care for the LEP population. Based on Civil Rights Law, the federal government mandates use of interpreters, among other efforts, to assure equal access to health care. The focus on quality has gained ground as research provides evidence that language barriers can have a negative effect on the delivery of quality health care and contribute to poor outcomes. Even though research is scant, the implications of language barriers has led to accreditation and licensing entities such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO), National Board of Medical Examiners and National Committee for Quality Assurance (NCQA)) to also promote effective communication, which for the LEP patient includes the use of interpreter. More recent research points to language barriers as a risk factor for adverse events and a patient safe concern.

Generally, interpreters are believed to be impartial conduits, faithfully conveying statements made between patients and their doctors or other members of the health care team. Interpreters are seen as neutral persons with language proficiency in two languages and ability to accurately choose vocabulary to enable understanding across culture and language. This notion of the interpreter is based on a belief that ideal words or sentences can be produced to convey equivalent meaning in two languages. Research on interpreters in health care, what little is available, builds on this notion by studying linguistic errors, such as additions, omissions, substitutions, editorializations and false fluency. Studies rarely document or consider language proficiency of interpreters or their training; both significant attributes in an interpreted event. We will focus on these topics in future special reports.

Further, linguist researchers Davidson (2000) and Angelelli (2004), able to analyze bilingual conversations of actual medical encounters involving interpreters conclude that interpreters are not impartial conduits. Interpreters are not neutral; they are active participants replacing the voice of both patients and doctors often conveying information not spoken by either. Angelelli contends interpreters become owners of text, offering advice not given by physicians or conveying judgments of health status not uttered by patients; in a sense they are co-creators of interactions that occur between patients and their doctors. Interpreters were found to assume the provider's role in obtaining medical histories and giving medical related instructions. These studies tell us highly trained health care professionals, oftentimes relinquish control of communication with patients to interpreters who are minimally trained to solicit, screen, and evaluate medically related information and raise questions of ethical boundaries.

Lessons Learned

Interpreters in health care are given enormous responsibility, with few checks and balances. This is significant, when we consider how poorly prepared interpreters are to take on these responsibilities; often with untested language proficiency. In our work with the Hablamos Juntos Demonstrations, we found a high turnover rate among Spanish interpreters; most of them received little to no training for the job. Among those tested, 40% worked one year or less as a health care interpreter and 56% received no training to work as an interpreter. Of those that reported receiving training, 21% received less than one week of training.

Our work has taught us that solutions to language barriers often underestimate the difficulty in achieving equivalent meaning between two languages and assume interpreters are neutral agents. Combined, these premises may contribute to unintended clinical consequences. The first to discover this within health care delivery organizations, particularly hospitals, will be risk managers and those concerned with patient safety.

Even if language services were a reimbursable service today, working with our national demonstrations, we learned first-hand how difficult it is to meet the communication needs of LEP patients when hospitals must first develop, from scratch, the interpreter workforce needed. Every step requires traversing foreign terrain and building new competencies; it is much more than most health care organizations can deliver by themselves. Further, why should they have to? Over the course of this year, we hope to share our lessons learned and offer recommendations for policy and practice in health care. Like many challenges in today’s business environment, effective solutions will require partnerships within and across various sectors of our changing communities.

As the nation and many states renew efforts to achieve universal health coverage, the needs of the uninsured should be at the forefront. This is not always the case. Too often, health economist Paul Feldstein contends, legislative outcomes in health reform promotes the economic self-interests of stakeholders in the health care industry, not the interests of the public. Millions of average Americans, many with health coverage, are unable to comprehend and act on health information they receive from their doctors; this is more true for those with limited English. With health reform, we have an opportunity to place emphasis on policy alternatives to address health communication needs of all Americans; especially for those patients unable to speak English.

Reform to achieve safe, quality health care for all patients will need to acknowledge the diversity of the nation's population. Today in the U.S., 60% of children under age 5 are children of color and many of them belong to non-English speaking homes. In states like California where nearly 1/3 of residents are foreign born and one in five speak English less than "very well", communication is vital to providing safe, quality care to all patients, regardless of the language they speak. But for the population that doesn't speak English very well, it's an even bigger challenge.

Research increasingly points to patient comprehension of health information as a significant barrier to receiving safe high-quality health care; language and cross-cultural communication differences are at the heart of ineffective communication. According to JCAHO, communication breakdowns were the primary root cause of unexpected deaths and catastrophic injuries that occur in hospitals. Moreover, many Americans today do not receive the proper standard of care and disparities in health and access to care persist for ethnic minorities and the poor. Highly concentrated among these populations are persons with limited English proficiency, immigrants and those with low levels of health literacy. These populations suffer higher rates of chronic and costly conditions as heart disease, obesity and diabetes. The potential benefit of health coverage is enormous, but any reform must keep communication across culture and language as a critical issue.

Policymakers need to consider the connections between language, culture and health literacy when crafting health reforms and balance the voice of lobbyists representing major health system stakeholders whose economic survival depends on the flow of dollars. Any health reform proposal needs to be patient centered, focusing on redesigning health care systems financing in terms of how well it will meet the needs of a growing and diverse population.

Hablamos Juntos Call for Translation Quality Assessment Tool Raters

Though federal law requires health care organizations to have vital documents translated from English into other languages, obtaining translated health materials of good and accurate quality continues to be a challenge for the health care community. In an effort to improve the quality of translated materials, Hablamos Juntos is currently recruiting bilingual interpreters and translation experts to be raters of a "Translation Quality Assessment" (TQA) Tool prototype. For the recruitment announcement, please click here. For more information about the study, please click here. To apply, click here.

Online Medical Translation Course at the University of Arizona

The Department of Spanish and Portuguese at the University of Arizona will be offering an online medical translation course starting in 2008. The course is funded by a grant from the Arizona Board of Regents and will be designed by Dr. Sonia Colina, a member of the HJ Scholars Network and translation pedagogy expert. "Medical Translation" is the pilot course for a future Online Translator Education Program that will feature research-based, innovative curriculum taught by professional and academic staff. Recruitment and applications will be accepted starting in September of 2007. For more information, contact Sonia Colina.

Seeking Candidates for the 2007-2008 Cultural Competence Leadership Fellowship

The Cultural Competence Fellowship is designed to enhance leaders' abilities to assess their organization's strategic priorities and community needs; implement a system to collect and report patients' race/ethnicity and language data; build awareness and communicate value of diversity and cultural competence strategies; mobilize and pilot organization-wide teams and task forces; enhance training mechanisms aimed at educating health care employees, clinicians, students, and executive leaders; apply tools and practices to address health care disparities by effectively linking cultural competence strategy to patient safety and quality improvement activities and more.

This transformative learning opportunity for health care leaders and teams is sponsored by the Health Research and Educational Trust (HRET), the Institute for Diversity in Health Management (IFD), the National Center for Healthcare Leadership (NCHL), and the AHA's Health Forum. Through a powerful combination of a diverse faculty, peer coaching from leading innovators, all-inclusive curricula, and action learning projects, participants strengthen their capacity to influence change. Applications are now being accepted. Limited space and scholarships are available. Download the brochure and application here.

Call for Helen Rodriguez-Trias Award Nominations

The California Department of Health Services, (CDHS), Office of Women's Health (OWH) requests nominations for the sixth annual Helen Rodriguez-Trias Award for Excellence in Community-Based Women's Health Leadership. The award will recognize an organization or individual who has demonstrated leadership in promoting women's health services at the community level. Eligible candidates must be a California resident or organization that is currently engaged in or has completed one of the following at the local level:

• A successful community-based program to promote women's health in California;
• A community advocacy effort to improve women's health in California; or
• An innovative research project to address California women's health concerns.

Nominations for the Helen Rodriguez-Trias Award must be submitted on-line, e-mailed, postmarked, or faxed by March 16, 2007. The award recipient will be announced in early May 2007. Click here for more information.

New Resources

The Joint Commission Introduces Guide to Improving Health Literacy

Health care leaders are responsible for creating and maintaining organizational cultures of quality and safety. Among the key systems for which leaders must provide stewardship is communications. "Improving Health Literacy to Protect Patient Safety" discusses this important issue and provides recommendations of how to achieve health literacy in your organization. For the white paper, click here.

Hablamos Juntos II – Language Policy and Practice in Health Care funded by the Robert Wood Johnson Foundation to disseminate lessons learned from ten demonstration sites around the country and to set standards and create practical tools for developing useful health materials in languages other than English.

More on Hablamos Juntos...