The Issue: Limited English patients encounter language barriers at many points in their search for health care, from the moment they try to make an appointment through their entire visit including discharge and referrals. These communication challenges affect access to quality health care; patients often delay treatment until their health needs become urgent. Examining access points - junctures along the health care visit where patients must communicate with staff - offers an opportunity to think strategically about language barriers and to develop transaction specific solutions, or “place-based” solutions. Place-based solutions apply problem solving to events of a specific time and place. The same way that health care organizations consider and plan for the care of those with physical handicaps, vision impairment and the elderly, they can also prepare their staff to receive and respond to patients with limited English proficiency.
In This Section: We’ll discuss a systems approach to improve how health organizations respond to LEP patients. We’ll explore low-tech and high-tech solutions developed by Hablamos Juntos demonstrations that improve patient flow, making systems more effective for all patients. Solutions tailored for specific transactions can include use of: patient greeters, navigators, escorts, help desks, phone lines, maps and brochures, pre-recorded messages, electronic kiosks, directories, and switchboard operators, among others.
It bears repeating: patients with limited English skills experience barriers before, during and after a health care visit. Due to the interdependent nature of health care organizations, expecting employees and patients to wait for an interpreter to enable communication creates problems for both groups. Waiting for effective communication also impedes the health care organization’s ability to move all patients through their visits. click here, for a discussion on the interdependence of relationships within health care organizations .
A patient’s health care visit and its outcome are impacted in large and small ways by all the interdependent parts of the health care organization. A systems approach to language access is based on the premise that a health care organization is comprised of regularly interacting or interdependent activities. So in order to effectively address language barriers, we need to understand how each interdependent part affects the others and focus on building response capacity within each one. Developing one program or department for language services places an undue burden on that part of the health care organization to resolve all the communication needs of every part of the organization, a task not easily accomplished without a systems approach.
The systems approach described here shifts the focus from traditional programmatic methods to looking at how the health care organization can overcome language barriers throughout the patient’s visit. As a result, a systems approach begins with an examination of communication needs from an LEP patient’s perspective as he/she travels through the health care system. The main emphasis of this examination is to learn what happens when there are language barriers. How do employees respond to patients with whom they cannot communicate? What alternatives do they have if interpreters are not available? Though interpreters can help patients navigate the care delivery experience, no single strategy will fulfill the needs of LEP patients throughout the continuum of a visit. Health care organizations that rely solely on interpreters will soon find that their reach is limited to only small manageable numbers of visitors and becomes increasingly expensive as that number grows. (For more information on Interpreter Services, click here.)
The diagram below shows typical access points associated with a health visit where information must be exchanged before the patient can proceed down the health care continuum. Each of these access points requires effective communication to ensure positive health outcomes. Are the actions of employees guided by policies and procedures or are they left to their own creative solutions?
Typicial Communication Junctures for a Health Visit
Each box represents a stop along the health care path. Many stops are routine “communication junctures” where administrative or clinical information must be exchanged. At each access point, language barriers influence: 1) how the patient experiences health care delivery, 2) the information received and given, 3) decisions made or opinions formed by both providers and patients, and 4) the quality of care received.
Health care organizations that look at these access points carefully can systematically identify communication needs and then develop strategic place-based solutions that will allow interpreters to be used for situations where they are most needed. Studying how to improve access and services for the LEP population will also inform the health care organization about how to improve communication for all patients.
Interpreters are a Finite Resource
When health care organizations rely primarily on interpreters, the challenge is to have them available where they are needed, when they are needed. Relying exclusively on interpreter services for all interactions is not an efficient or financially viable option. Working with the Hablamos Juntos demonstrations, the limits of using interpreters as the primary solution became evident immediately.
As the patient volume exceeds capacity in settings where interpreters are the only solution to language barriers, common problems arise that erode the effectiveness of this approach. To see a list illustrating common consequences and limitations of relying only on interpreters for overcoming language barriers, click here.
There are ways to use interpreter resources effectively and to create other tools to overcome language barriers throughout your health care organization. By analyzing the exchange of information that takes place at each access point you can create place-based solutions.
Place-based solutions are tools, aids, routines, protocols or specific instructions created for a defined place and purpose. Health care organizations can develop simple tools and “how to” protocols for employees to follow when an interpreter is not available. Place-based solutions for language access are practical aids and tools used by employees that enable LEP patients to proceed through their visit without undue delay. Using a variety of applications or place-based solutions increases a health care organization’s ability to ensure that all patients receive prompt attention and a smooth flow through their visit, regardless of their English ability. Placed-based solutions can make the difference between serving your LEP patients and creating avoidable backlogs or delays that can be prevented with simple information exchange.
Routine transactions, like registration and check-in/check-out functions, which are repeated with each patient and sometimes take place repeatedly and in various service departments (e.g.: radiology, laboratory, etc.) are perfect candidates for place-based solutions. The idea here is to identify standard phrases or routines that are repeated with each patient and create solutions employees can use to help LEP patients through basic administrative processes without calling for an interpreter.
Developing place-based solutions begins by looking at routine encounters where limited English speaking patients may experience preventable confusion or delay. Check-in functions, for example, occur in various locations throughout a health care visit to acknowledge a patient has arrived and to initiate a health encounter. These are often the first place patients experience communication problems. Although check-in functions are similar, each one is designed for a specific location and purpose. Designing place-based solutions begins by examining one of these access points to first learn how employees are currently dealing with language barriers and to explore whether language barriers can be overcome by the assigned staff, before relying on an interpreter to intervene.
Five simple steps to creating place-based solutions:
- Study common access points, one at a time. The tasks carried out at access points (e.g.; check-in desks) are unique. The transactions that take place are designed for a specific location and purpose. The details of these transactions need to be understood. A list of transaction types and scripts of the information exchanged, with each type of transaction, need to be made.
- Learn what employees do when they encounter patients they are unable to talk with, either because of language barriers or other communication impediments, such as with deaf patients. In a nonjudgmental or critical way, learn what creative solutions employees have developed. Match what employees believe they are supposed to do with official organizational guidelines. Perhaps additional work is needed to disseminate existing strategies and protocols. Seek to understand why there may be differences; are the resources needed available? The goal of these observations is to learn and to identify opportunities for improvement. Determine whether spontaneous creative solutions need to be formally adopted or supported. Identify areas for more research and attention.
- Identify encounters where the information exchange is repetitive and predictable. Not all health interactions are created equal. While many encounters are complex and unique to a particular patient, many others are routine interactions that can take place with some foreign language tools or aids. Hablamos Juntos demonstrations developed a variety of tools, ranging from pre-recorded messages to computer-assisted communication to aid employees in routine encounters.
- Test, adapt and retest. Test new solutions in practice before they are adopted for use with patients. Developing effective solutions requires trying them out in real time, learning how well the prototype works and using the experience to adapt the solution. Rapid cycle quality improvement techniques work well to test and refine place-based tools.
- Develop organizational support. Successful implementation of place- based tools, as any new practice, requires supportive infrastructure and the capacity to reinforce and support the use of these tools. An environment that supports the use of the tool is needed. This may take developing physical and technological infrastructures to accommodate new technology. For example, ready access or storage space may be needed for the tool or technical support to answer questions as they arise.
Using simple tools and aids designed for specific locations and purposes enable employees to carry out simple tasks, rather than relying on interpreters by default. Creating an environment of problem solving and active engagement to overcome language barriers can increase access for patients with limited English ability and increase their comfort during a visit. Making visits easier can also contribute to the quality of the visit. For a list of benefits others enjoy with place-based solutions click here.
By using place-based solutions appropriately, rather than choosing interpreters by default, health care organizations can increase LEP patients’ access to care and consequently their quality of care.
Low-Tech and High Tech Solutions
Hablamos Juntos demonstrations were encouraged to think strategically and create place-based solutions with an emphasis to access points. The results are a number of innovative alternatives that decrease language barriers for routine and non-critical interactions (i.e.: at registration desks or when offering way-finding instructions). These tools fall into two main categories: low-tech solutions and high-tech solutions. Below you will find examples of tools developed for a defined purpose within a defined health care organization. These tools are examples of solutions that may work in your health care organization.
Low-tech solutions include printed materials including cards, handouts, diagrams, posters, signs and other basic resources and technology that, when used in the settings for which they were designed, facilitate information exchanges and enable English speaking employees to overcome language barriers. Useful low-tech materials are simple to read, easy to access and might include step-by-step instructions that can be handed out to patients. Poster boards, diagrams, and pictures can be used to reinforce concepts described in written materials. Each solution was designed and is to be used for a defined purpose, so successful implementation depends on trained users. English descriptions of the foreign language content should always be included to enable appropriate use.
The staff’s understanding of the intended purpose and contents of these solutions is imperative for successful implementation; English descriptions of the content must be available.
Printed materials with foreign language content are the least expensive type of language service and are especially useful for literate patients. These cards can be used to help patients make their way from the hospital entrance to the exam room or other destinations without incurring major delays waiting for an interpreter to help. Printed cards are limited in scope, however, and are of limited use beyond routine administrative functions.
Standard recorded messages are commonplace with most telephone answering services. Pre-recorded messages give basic information, confirm location, request identifying information and give basic instructions. For example “this is outpatient registration” may help confirm whether the patient is in the right location or not. A recording saying “please write the name of the patient you wish to visit” or “ please write your name, address and phone number” can be used to determine how to direct a visitor or whether the patient has an appointment at that location. Simple instructions (“you have an appointment at …” or “please do not eat or drink anything for twelve hours before you get this lab work done”) also work well as pre-recorded messages. Messages recorded in English and the patient’s language offer a tool to at least expose the patient to the English version of the information provided on the tape. For a list of the benefits of using pre-recorded messages, click here.
Many initial access points are reached by telephone. Developing protocols to route calls to interpreters or bilingual employees are simple tools that can be used at many access points. For health care organizations with interpreter programs, protocols to direct incoming telephone calls to an interpreter can be cost effective over commercial telephone interpreter services. If call volume is high, interpreters can be staffed to handle incoming telephone interpreting needs. In addition, line staff can be trained to request interpreter support over the telephone for simple administrative tasks as a supplement to other place-based tools. Finally, most businesses today offer callers the option to hear instructions in Spanish. Health care organizations can adopt this practice and formalize arrangements for responding to messages left in foreign languages.
Over the last ten years, the most rapid growth has been in smaller language communities. The number of Russian speakers has nearly tripled; Vietnamese and French Creole (including Haitian Creole) speakers have doubled. Health care organizations that serve patients from these smaller or emerging language communities may find commercial vendors offering telephonic interpreting a good alternative to in-person interpreting. Telephonic interpreting can be more cost efficient and the services can be accessible 24 hours a day. However, these services can be expensive and come with certain disadvantages. These include: inconvenient telephone availability, long waiting times, challenges in determining the language required, their training, health related experience, interpreting skills, finding the appropriate interpreter and uncertainty about quality related to the interpreter’s language proficiency in English or the target language. For more information, click here.
This automated health information database is accessible 24 hours a day and can be listened to as many times as the patient desires. It is especially beneficial for non-literate or illiterate patients. Patient instructions can be recorded into the library, which they can then access from home. It may be used in triaging if the available nurses do not speak a caller’s language. The downfall to this one-way communication product, however, is that the patient cannot share his or her symptoms.
High-tech solutions incorporate new and existing technology, computer software, electronic kiosks, use of portable devices like personal digital assistants (PDAs), laptop computers, tablet PC’s, phone systems with bilingual support, and messaging systems. These types of technology can be integrated with voice recording systems to convey recorded information in the preferred language of your patients. Kiosks with “Do it yourself” applications use step-by-step instructions on a computer screen to help a patient complete forms, register for services or obtain instructions and information about services in their own language. Kiosks are becoming more common, and utilizing them can help patients build a stronger sense of self-reliance and comfort with technology. With patients accessing information on their own, interpreters can focus on situations that demand their services.
Because of their mobility, handheld electronic devices are suitable for mobile healthcare staff, such as doctors and nurses, and other clinical and support staff. Devices like PDAs, Tablet PCs and other computerized technology can include electronic term glossaries, pre-recorded messages, diagrams and graphics that can be used to explain concepts and provide instructions to patients in languages other than English.
Healthcare database software can be divided into two basic types: a health information database for patient reference and a patient information database for providers. These databases can be built in several languages and can be updated as necessary with new information as needs are identified. Utilizing this software requires access to computer terminals and can be made easily accessible through the Internet.