Language Barriers in Health Care
To strategically build an efficient, effective and qualified workforce for providing language services.
Why It's Important:
In health care, language services are frequently provided by self-declared bilingual clinical providers and ad hoc interpreters, such as family members, friends or staff who have not been trained and assessed in medical interpreting. Research demonstrates that the use of unqualified individuals results in increased medical errors, less effective patient-clinical provider communication and poorer follow-up and adherence to clinical instructions, as well as possible conflicts with patient privacy rights. The presence of a readily accessible, qualified language services workforce is necessary for a high-quality program.
How to Do It:
Hospitals are unique in their resources and patient needs, and must consider the pros and cons of using a mix of language services modalities (e.g., telephonic, face-to-face) and staff (such as whether to use full-time or part-time employees or to use vendors). The following five steps toward building a language services workforce emphasize the importance of determining who is qualified to interpret and how they can most efficiently and effectively meet demand for language services in your organization:
Please note the following terms:
Interpreter: A person who translates a message spoken in one language into a second language. Health care organizations take a variety of approaches to employing interpreters, including: hiring interpreters as full-time or part-time staff, hiring contract or freelance interpreters, or using dual-role staff.
Dual-role staff: A staff member with proficiency in more than one language who is asked to interpret for patients with language needs. This could be a clinical or nonclinical staff member.
Bilingual provider: A health care provider with proficiency in more than one language, enabling him or her to provide services directly to patients with language needs in their preferred language.
Ad hoc interpreter: An untrained person, such as a family member or friend, or a bilingual staff member who has not been trained in medical interpretation and assessed for medical fluency.
Translator: A person who translates written texts. Health care organizations take a variety of approaches to employing translators, including hiring translators as full- or part-time staff or hiring contract or freelance translators.
1. Define “qualified to interpret” and “qualified to provide care in another language” for your organization.
Establish basic qualifications for interpreters and translators:
- Medical fluency in English and the target language
- Training in medical interpreting/translating
- Experience in medical interpreting/translating.
Develop a plan to train interpreters and translators who don't meet qualifications.
Create a process to assess the performance of interpreters and translators. In many organizations, interpreters provided by vendors, including telephonic interpreters, are not routinely evaluated for quality. Work with your vendors to meet the same standards that you have implemented within the organization and, if possible, integrate these standards into vendor contracts.
Establish basic qualifications for bilingual providers, including fluency in English and the target language.
Develop a process to assess bilingual providers.
Adopt standards of practice and a code of ethics to reflect the performance expected of interpreters and translators.
2. Identify the members of your language services workforce.
Work with an interdisciplinary team to develop a language services workforce model that fits your organization.The team should include:
- Clinical leadership
- Front-line staff
- Human resources
- Risk management.
Use information obtained from your organizational needs assessment such as languages spoken in your community and current capacity to meet language services demand to guide the development of your workforce. Input from patients also is critical to ensure that your model is driven by their needs.
Many hospitals use a mixture of full- and part-time interpreters for the most commonly encountered languages, and vendors (e.g., telephonic, face-to face, contract and freelance interpreters) for less common languages and off-site and after-hours encounters. A mixed staffing model allows flexibility and can be altered according to changing demand.
Some hospitals employ staff who may be ideal for use as a dual-role staff. Before hiring outside help to function solely as medical interpreters, you may want to look within your organization for bilingual staff.
Identify the modalities of interpretation to meet demand in your organization, such as:
- Face-to-face interpreting
- Telephonic interpreting
- Video interpreting
- Remote simultaneous interpreting systems.
Adapt procedures for providing interpreter services for certain high-volume areas in your organization. For example, departments such as billing and registration may find using the phone more efficient than requesting a face-to-face interpreter.
Work with human resources to identify and recruit individuals potentially qualified to interpret or provide care in another language. Examples of ways to identify bilingual providers and dual-role staff include conducting surveys, accessing information from the language-related questions asked during the hiring process and speaking to department managers who may be aware of their staff's bilingual abilities.
Tip: Dual-role staff and volunteers who have been assessed for language fluency, but not trained in medical interpreting, can play a valuable role in providing nonmedical information such as directions and billing. Reserve trained and assessed medical interpreters for medical encounters, while bridging the language gap in other departments with dual-role staff and volunteers.
Identify and determine qualifications for the individuals responsible for management and administrative duties for the department, including those who are responsible for:
- Overseeing the department
- Scheduling and dispatching interpreters
- Entering and managing operations data
- Managing interpretation and translation staff and vendors
- Monitoring and improving quality in the department.
3. Develop and disseminate policies and guidelines around the use of language services.
Develop policies and guidelines around the provision of interpreter services.
Work with an interdisciplinary team of clinical providers, patients and interpreters to develop guidelines on the use of different modalities of interpretation available in your organization, taking into consideration:
- Complexity of the medical encounter at hand
- Patient condition and ability
- Sensitivity of the issue being discussed
- Emergent nature of the case
- Location of the medical encounter
- Availability of language services providers.
Examples of frequently provided guidance include: using the phone for interpretation in an emergency until an interpreter can be physically present; using an in-person interpreter for complex or serious cases such as delivering bad news; and using a telephonic vendor for routine outpatient visits in remote off-site clinics.
Develop policies and guidelines around the provision of translated materials.
Develop a curriculum and train clinical staff on how and when to use the various types of language services provided by your organization.
4. Evaluate and assess your language services workforce.
Use performance measures to monitor the quality of your language services workforce. You may wish to track the percentage of interpreters, dual-role staff and bilingual clinical providers who are interpreting in your organization and who meet basic qualifications.
Use performance measures to monitor interpreter and translator efficiency and productivity. Interpreters often spend time in tasks other than medical interpreting, such as traveling to appointments, paperwork, scheduling and non-medical interpreting. Consider using an internal efficiency or productivity measure to find out whether qualified, skilled medical interpreters are spending as much time as possible doing their primary job of medical interpreting. Keep in mind that interpreters also need time for breaks, staff meetings and professional enhancement activities.
Use performance measures to monitor the timeliness and efficiency of language services. Patients and clinical providers often report reluctance to using language services due to potential delays in obtaining an interpreter following a request. Interpreters can also experience delays when waiting for a clinical provider to arrive. Develop measures to address these concerns and to ensure that patients, clinical providers and interpreters do not wait too long.
Assess whether your language services workforce is effective in terms of:
- Meeting demand
- Providing high-quality services
- Budgeting for program elements.
Tip: In addition to examining your data, talk to clinical providers who use language services to determine whether the services are meeting their needs and the needs of their patients. Also, be sure to talk to those that do not use language services to identify barriers and ways to improve access to your services.
5. Develop strategies to improve the efficiency and effectiveness of your language services workforce.
Set targets for department performance based on productivity measures. Set realistic targets that consider the demands of your employees' work day. Some hospitals consider interpreters who spend about two-thirds of their day in medical interpretation to be very productive. This allows for necessary activities such as breaks and time to get to appointments.
Make adjustments to your language services workforce based on your evaluation and assessments.
Tip: In order to ensure that language services are immediately accessible, some hospitals have placed speakerphones or dual handset phones in areas such as the emergency department to provide more timely services to patients with language needs.
Set an organizational goal to have all bilingual clinical providers in your organization assessed for fluency.
Develop opportunities for the career advancement of interpreters and translators. Interpreters may be given the opportunity to move to an additional level of practice by specializing in a clinical condition or subpopulation, or by pursuing a certain number of hours of professional training beyond what is required by the organization.
Develop systems to support the efficiency of interpreters and translators.