Language Barriers in Health Care
To design systems and processes that support getting the appropriate interpreter services to patients identified with language needs in a timely manner.
Why It's Important:
The right workforce is just one component of a high quality language services program. Systems that support delivering appropriate interpreter services to patients are essential to predicting demand, reducing unreasonable delays in care and maintaining patient and clinical provider satisfaction.
How to do it:
Regardless of its technological sophistication, a language services department must work with other departments to identify effective mechanisms for meeting a patient's language needs. The following five steps toward getting an interpreter service to the patient emphasize building strong systems and processes that support your interpreter services workforce, while communicating with other departments:
1. Develop policies and procedures for how and when to access interpreter services.
Work with clinical providers to determine when interpreter services are needed. Organizations should identify which situations require a qualified medical interpreter to efficiently and effectively allocate language services resources. It may be a better use of resources to use individuals unqualified to interpret (e.g., volunteers and untrained bilingual staff) for activities such as patient navigation, while reserving qualified interpreters for clinical encounters with a patient such as during initial assessment, discharge, and obtaining informed consent. For encounters requiring significant clinical communication with a patient, organizations should use either a trained and assessed medical interpreter, including dual-role staff, OR an assessed bilingual provider.
Work with registration/scheduling, clinical providers and other departments to determine the most efficient mechanism(s) for accessing interpreter services. Keep your process for accessing interpreter services simple. If a clinical provider or staff member has to spend time searching for a phone or reading instructions in order to access or request the service, chances are he or she won't.
Develop policies and procedures for requesting an interpreter service, including what information is needed to schedule the service, such as:
- Time of appointment
- Time interpreter service is needed
- Length of appointment.
Procedures for requesting an interpreter service may vary based on the time between when the request is made and the patient's appointment. For example, the procedure for requesting an interpreter service for an inpatient or a patient in the emergency department may differ from the procedure for requesting an interpreter service for a patient with a clinic visit scheduled to occur in two days. Examples for mechanisms for requesting an interpreter include telephone, intranet or computerized prescriber order entry.
Work with information systems to automate requests for interpreter services. In many organizations, registration and scheduling are linked to language services. For example, the physician may be concurrently scheduled with the interpreter or a notification may be sent when an appointment is made with a patient with language needs. Your organization may use two or more registration and scheduling systems. Work with information systems to get software on the inpatient and outpatient sides to be able to “talk” to the language services department.
Include a process for receiving requests from clinical providers and/or patients for a specific modality of interpretation. Even organizations that rely primarily on one mechanism for interpretation, such as telephonic interpreting, may find cases in which they are asked by the provider or patient to secure a different modality of interpretation. For example, a patient with language needs that has hearing difficulties may prefer a face-to-face interpreter.
Develop a process for identifying clinical providers or sites within the organization that do not request services for patients who may need them.
2. Create a plan and acquire systems for responding to interpreter service requests.
Work with clinical providers to develop policies for prioritizing interpreter services requests; these polices should consider:
- Severity of the patient's condition
- Emergent nature of the case
- How long the patient or clinical provider has been waiting
- Proximity of the nearest language services provider.
Acquire a system or systems for tracking and filling interpreter services requests. Organizations with high volumes of patients with language needs typically use a system (often run by individuals called “dispatchers”) for prioritizing, tracking and filling interpreter services requests to manage resources. Those organizations with few patients with language needs may be able to operate without this type of system and instead use direct access mechanisms for interpreter services (i.e., provider calls the interpreter or telephonic vendor directly).
Interpreters tasked with triaging requests may find it difficult to provide optimal communication if they are interrupted during a patient encounter. Try to keep other demands from impeding their ability to do their primary job.
Some programs distinguish emergency requests by setting up a phone queue or messaging system for less urgent needs such as assistance with calling a patient to schedule an appointment or to discuss follow-up care. This allows staff to respond to pressing requests during peak hours and return calls during slower periods.
If applicable, develop a procedure for notifying clinical providers and staff which modality of interpretation their patient has been assigned. Programs that provide varied language services should consider the clinical judgment of the clinical provider and allow him or her the opportunity to express the desire for a preferred modality of interpretation, especially when considering the condition of the patient.
Develop a daily schedule of interpreter service activity. In addition to scheduling face-to-face interpreters, scheduling interpreter services provided telephonically or through video can help ensure that patient and provider wait times are reduced.
Tip: Language services programs use a variety of scheduling systems that range in precision and accuracy. For example, some hospitals may offer block scheduling of interpreters in certain areas for a designated time each week. Others may calculate average travel time and average length of encounter to determine how long an interpreter will need to perform in a particular area of the organization. Schedules of interpreter activity may be determined up to 24 hours ahead of time and revised the day of, or they may be determined in real time if the organization has a sophisticated scheduling system.
Some programs may choose to operate without a schedule due to greater availability of resources or use of systems with immediate access to interpretation, such as telephonic and video interpretation. However, most programs find that demand is difficult to manage without a schedule.
3. Use communication systems to increase efficiency in the delivery of interpreter services.
Work with information technology to determine how individuals responsible for tracking and filling interpreter service requests can receive information about clinical schedule alterations, such as:
- Unscheduled procedures.
If applicable, work with information technology to determine how interpreters and any other individuals responsible for tracking and filling requests can communicate with each other, such as by:
- Two-way pager
- Cell phone for voice or text messaging
- Two-way radio
- Handheld personal digital assistant or “palm” device
- House and unit desk phone
- E-mail or fax.
In order to create a more efficient system for communicating with devices relying on written communication (e.g., text messaging devices), you may want to use a form of standardized codes or phrases to communicate.
Tip: Your process for transferring request information between interpreters and any other individuals responsible for tracking and filling requests should include a mechanism for transferring information from one shift to the next. This process may need to be modified for vendors.
Tip: Rather than having interpreters return immediately to a central office when they have finished, consider a policy that has them call the office before leaving, to check if there are nearby requests for their services.
4. Evaluate your organization's performance in getting interpreter services to the patient.
Use performance measures to monitor the efficiency and timeliness of interpreter service delivery.
Use performance measures to monitor the effectiveness of interpreter services delivery. The true test of your program is whether patients who need language services actually receive them. Assess whether patients with language needs receive qualified services at critical points in the care process. If necessary, start small by looking at language services provided at initial assessment and discharge in one unit.
Evaluate the accuracy of your interpreter service scheduling system.
Create forms/logs and reporting requirements to capture information about program trends.
Assess whether the processes, systems and equipment for accessing an interpreter meet the needs of every department. You may wish to either establish a simple mechanism for clinical providers and staff to give feedback about interpreter services access or identify a clinical liaison from each department to provide regular comments.
Determine whether the physical placement and modalities of language services within your organization facilitate the timely provision of services.
5. Develop strategies for improving interpreter services delivery and operations.
Identify ways to improve access to interpreter services. In order to ensure that clinical providers have immediate access to an interpreter even during peak times, many programs have the person responding to telephone requests offer telephonic interpretation instead of, or while waiting for, an in-person interpreter.
Involve patients, staff and clinical providers in quality improvement efforts. Eliciting feedback from the individuals that use your services is critical to determining what works, what doesn't work and how things might be improved.
Develop simple processes for notifying and reminding clinical providers of a patient's language needs and how to access a language service.
Look for opportunities to improve the accuracy of your scheduling system.
Tip: Improve your ability to predict demand by figuring out clinics' unique schedules, such as those with appointments that routinely run 10 minutes behind or those that usually require 30 minutes. Additionally, prescheduling interpreters for encounters such as scheduled surgeries and physical therapy sessions can help anticipate demand.
Test new systems and technology before fully committing to them. For example, you can use two different clinical areas, such as an inpatient unit and an off-site clinic, to test the usefulness and adaptability of the technology.
Match the choice of location and modality of interpreter services to the patient and to the unit using the service. For example, you may find that the billing and pharmacy departments may find immediate access telephonic interpretation more efficient than face-to-face interpretation.