Patricia Bickel. credit. Providing effective health care in your patients languages

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1 Volume Nine Number Four Published Monthly Patricia Bickel Compliance and Privacy Officer, Director, Professional Integrity Program for University of Southern Florida Health page 14 Save the Date! Special Focus: Dollars and sense of executive compensation Earn CEU credit see insert Providing effective health care in your patients languages Also: page April page 4 Proposed changes to the clinical trial National Coverage Determination

2 Providing effective health care in your patients languages Editor s Note: Michael Greenbaum is the president and CEO of CyraCom, a language services company serving the U.S. health care industry. He may be reached by at mgreenbaum@cyracom.com or by telephone at 520/ , ext With all the rules and regulations that U.S. hospitals must comply with these days, it s easy to become overwhelmed and frustrated with the responsibilities. When it comes down to it, the easy rules to comply with are those that are spelled out and specifically mandated. However, in reality, we know that many are not so straightforward and understandable. Language access can be one such murky area. What are the federal regulations for language services? How can a hospital become and stay in compliance with them? What are the cost considerations? These are just some of the questions that come up when considering oral interpretation and written translation for Limited English Proficient (LEP) patients. One thing there is no question about is the increasing diversity in the United States. According to the U.S. Census Bureau s 2005 American Community Survey, the United States saw a 14.7% increase in its foreign-born population from 2000 to During this time, the number of people speaking a language other than English at home also increased by 10.6%. In 2005, 19.4% of the U.S. population spoke a language other than English at home. With almost one-fifth of the population preferring a non-english language, hospitals By Michael Greenbaum have also felt the impact. The changing face of the U.S. patient population creates new diversity challenges. Hospitals must take a broad perspective of diversity, because it s not just ethnicity, but also religion, cultural customs, language, and dialect. Language needs are only one way to consider the diversity of a patient population. It s important to plan ahead to meet the compliance requirements of the existing federal guidelines for language services. Waiting too long may mean playing catch-up, once there is a problem or question of compliance. Hospitals should not seek help just to get in compliance with these guidelines. Instead, they should take a step back from compliance and do it because it s the right thing to do. Learning how to respond to growing diversity in the patient population can result in improved quality of care, better patient and employee satisfaction, quicker diagnoses, and lower costs. Research has shown that LEP patients face linguistic barriers when accessing health care services. As noted by a cultural and linguistic workgroup of the Health Industry Collaboration Effort, patients with linguistic barriers are less likely to seek treatment and preventative services, which can create poor health outcomes and longer hospital stays. 1 Federal guidelines Most federal guidelines stem from Title VI of the Civil Rights Act of 1964, which prohibits discrimination based on national origin for any program receiving federal financial assistance.2 Title VI is the oldest and most basic Michael Greenbaum of regulations requiring meaningful access to health care and equal care for all patients, but several other entities have also added regulations to the mix. In August 2000, President Bill Clinton issued Executive Order 13166, requiring each federal agency to issue guidance for improving access to programs and activities funded by the agency for LEP individuals. This resulted in federal agencies publishing and republishing their LEP guidance documents. Also in August 2000, the Office of Civil Rights (OCR) within the Department of Health and Human Services (HHS) issued its policy guidelines, not as a new law, but as clarification on Title VI. Service providers who do not provide meaningful access for LEP individuals are seen as discriminating based on national origin. OCR recognized the need for flexibility in the provision of language services and calls on hospitals and health care contractors to: 1) Assess the language needs of their patient population 2) Develop written policies on how these populations can obtain competent language services, including both oral interpretation and written translation services 3) Train staff for effective implementation of these policies

3 4) Have methods for notifying persons of their right to language services 5) Monitor the policies 3 The Health Care Financing Administration, now called the Centers for Medicare and Medicaid Services (CMS), issued an August 2000 letter to all state Medicaid directors regarding interpreter and translation services. This letter explained Title VI responsibilities and included a copy of HHS guidelines. It also emphasized that federal matching funds are available for state expenditures related to providing and administering oral interpretation and written translation services for the State Children s Health Insurance Program and Medicaid beneficiaries. HHS s Office of Minority Health then came out with its 14 standards on Culturally and Linguistically Appropriate Services (CLAS) in December The CLAS standards are primarily directed at health care organizations; however, individual providers are encouraged to use the standards in their practices as well. Of these national standards, four directly address language barriers to care. Standards 4-7 cover language access services. 4, 5 These four linguistic standards are mandated instead of strongly recommended, as the other CLAS standards are, because of their derivation from Title VI. Standards 4-7 Standard 4: Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with Limited English Proficiency at all points of contact, in a timely manner during all hours of operation. Standard 5: Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. Standard 6: Health care organizations must assure the competence of language assistance provided to Limited English Proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). Standard 7: Health care organizations must make available easily understood patientrelated materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. The Joint Commission supports the CLAS standards as a key factor in the safety and quality of patient care. In its Hospitals, Language and Culture cross-sectional study, the Joint Commission recommends language services be provided beyond just the patient/ practitioner encounter, that all hospital staff should be trained in how to access language services, and that there be monitoring and reporting of LEP situations. 6 Where the Health Insurance Portability and Accountability Act (HIPAA) is concerned, the privacy of patient information does include interpreted conversations. Interpreters may be a member of the workforce (on staff) or a business associate (telephonic services or contracted interpreters), but they are bound to uphold the HIPAA privacy rule. Generally, monitoring of interpreting for quality assurance purposes does not violate HIPAA. Effective interpretation services must keep this information confidential and destroy any notes made during the call for best practice purposes. Hospitals are subject to fines and can lose their federal funding if they are found to be noncompliant with OCR s regulations, not to mention the negative media attention that can arise from OCR complaints about a hospital. Local activist health organizations, citing the legal guidance for lawsuits, have also filed lawsuits against hospitals. 7 The HHS Policy Guidelines on LEP regulations under title VI provide numerous safe harbors. To be in compliance with Title VI, an entity needs to provide written materials in non- English languages with the following provisions: a. The HHS recipient provides written translations of vital documents for each eligible LEP language group that constitutes 5% or 1,000 individuals, whichever is the less, of the population of persons eligible to be served or likely to be affected or encountered. Translation of other documents, if needed, can be provided orally, or: b. If there are fewer than 50 persons in a language group that reaches the 5% trigger in (a), the recipient does not translate vital written materials but provides written notice in the primary language of the LEP language group of the right to receive competent oral interpretation of those written materials, free of cost. Unfortunately, these are guidelines instead of requirements. Compliance officers should consider the best practice of implementing these benchmarks within their organizations. Compliance is based also on balancing four factors: n the number or proportion of LEP persons eligible to be served or encountered; n the frequency with which LEP individuals come in contact with the program; n the nature or importance of the program, activity, or service provided by the program to people s lives; and n the resources available to the grantee/recipient or agency, and costs. In these safe harbors, perhaps the key word is that LEP patients deserve the right to competent oral translation. This necessitates Continued on page 7

4 effective health care in your patients languages...continued from page 5 thinking about and working out competent interpretation. Some promising practices that OCR lists to advance service to LEP populations without overburdening hospital staff or resources include use of the Internet to store and retrieve translated documents, state-of-the-art medical interpretation systems, community language banks, and telephone information lines. 8 A national survey in 2006 by the Health Research and Education Trust (HRET) sought to better understand the processes and resources available to hospitals in providing language services to LEP patients. Key findings include 63% of hospitals encountered patients with LEP either daily or weekly and 88% of hospitals reported providing language services during off hours. 9 While these numbers show increasing need for interpretation and translation services, 92% of hospitals also indicated that telephonic services were the most readily available resource for providing language services. OCR provides several examples of practices that may violate Title VI, such as providing services to LEP persons that are more limited in scope or of lower quality. A major one is that if a hospital subjects LEP persons to unreasonable delays in the delivery of services, there could be a violation. Research shows that being unprepared for serving LEP persons creates longer wait times. Hospitals need to be prepared so they do not burden their patients both LEP and English-speaking with longer wait times. An analysis of language barriers to U.S. health care in the New England Journal of Medicine acknowledges that without interpreters, results can include higher costs and inferior medical care, both of which can be related to longer waits. The article notes that many hospital LEP patients who need interpretation don t get it, which can lead to poor and sometimes lifethreatening medical care. Ad hoc interpreters are more likely to commit errors with clinical consequences and are unlikely to have had training in medical terminology and confidentiality. 10 In a medical setting, communication is often compromised by language barriers, which in turn compromises the quality of care. Understanding and serving LEP patients effectively improves their hospital experience, the quality of care they receive, and their health outcomes. Serving a diverse population To ensure compliance, the OCR recommends that effective programs assess the language needs of the populations served, develop a comprehensive written policy on language access and assurance of meaningful communication, train staff to know the policy and work effectively with LEP patients and interpreters, and monitor the language assistance program to insure meaningful access for all LEP individuals. One step hospitals can take is to participate in a medical interpreter training program, directed by many state medical centers as well as the Cross Cultural Health Care Program. 11 This is a 40-hour or six-week class teaching bilingual staff how to interpret medical situations. The class reviews medical terms, vocabulary, and different areas of medicine, and teaches legal issues and ethics. Other resources for language assistance besides on-call staff include community volunteer networks, telephonic interpretation services, and private interpreter agencies. In its 2004 guide to language interpreter services, the Minnesota Medical Association offers these suggestions to maintain an environment that ensures equal access for diverse populations: n Support staff working respectfully and effectively with LEP patients; n Create a comprehensive strategy to provide culturally and linguistically appropriate health care; n Maintain ongoing staff education in cultural competence; n Provide patients with LEP access to interpretation services; and, n Collect accurate information about the cultural diversity of the facility s service area. An efficient hospital diversity program that includes staff preparation, effective communication with staff and patients, and cultural competency training helps hospitals steer clear of ineffective treatment and provide the best patient care possible. A critical response to increasing diversity is knowing the patient population and understanding its needs and background. Many hospitals are working to recruit more diverse employees, and hospital leaders are actively participating to ensure the success of diversity programs. Some health care facilities have instituted cultural competency programs. Others translate patient forms and informational material. Still others develop partnerships with community-based organizations to better understand their neighbors and to increase their cultural competency. Community hospitals, especially, are aware of the increasing need to incorporate diversity programs into their strategic plans. Some 2006 statistics from the CyraCom Language Index, which reports on language use at nearly 1,000 U.S. hospitals and health care facilities, show that the number of languages needed to communicate with patients at U.S. hospitals during 2006 grew to 143, an increase of 8% from Perhaps surprisingly, the Midwest leads the way with the Continued on page 9

5 effective health care in your patients languages...continued from page 7 greatest percentage increase in the number of languages needing interpretation in hospitals and health care facilities. The South, however, is close behind in this trend. 12 Diverse populations are no longer found almost exclusively in larger cities. Many LEP populations are also migrating to smaller cities throughout the country, such as Chattanooga, Tennessee; Raleigh-Durham, North Carolina; Richmond, Virginia; and Syracuse, New York. As a result, hospitals and health care facilities are finding they need to boost their language service offerings to accommodate LEP patients seeking medical treatment at their facilities. The data show that nationwide the top five languages needing interpretation are Spanish, Russian, Vietnamese, Korean and Arabic. Emerging languages (those being asked for with more frequency) include Burmese, Turkish and Amharic (Ethiopian). The real cost Different hospitals have different LEP patient populations and varying organizational resources. Many times it s not practical to hire trained medical interpreters for a given language. While cost is always a consideration, the cost of noncompliance can be greater when a lack of interpreters increases the costs of care as well as lost productivity. Compliance officers can factor in the ramifications. For example, a five-minute call with a telephonic interpreter to explain medication directions can cost less than $10. Contrast this to the dramatic increase in cost when a visit to the emergency room is needed because the patient took an incorrect dosage. Conclusion A study by the National Health Law Program agrees that one size does not fit all when providing language services. The future holds promising programs and activities that are now in progress to address language access concerns such as cost, high quality, effective interpretation, and needs measurement. 13 In the Community Access Monitoring Survey, sponsored by The Access Project, more than 25% of uninsured respondents who needed, but did not receive, an interpreter reported leaving the hospital without understanding how to take prescribed medications (compared to 2% of other respondents). 14 Health risks resulting from incorrect medication usage emphasize the need for oral and written instructions in languages of the patient population. On the other hand, more than 90% of LEP patients who did get interpretation said they would return to their present facility if they became insured. Hospitals need a real, implementable program for compliance to language services. Testing Continued on page 13 Relevant Federal Regulations for Language Services Title VI of the Civil Rights Act of 1964: No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. Executive Order 13166: Improving Access to Services for Persons with Limited English Proficiency (65 FR 50121, August 16, 2000): Every federal agency that provides financial assistance to non-federal entities must publish guidance on how their recipients can provide meaningful access to LEP persons and thus comply with Title VI regulations. Health and Human Services Office of Civil Rights: 1) Assess the language needs of their patient population 2) Develop written policies on how these populations can obtain competent language services, including both oral interpretation and written translation services 3) Have methods for notifying persons of their right to language services 4) Train staff for effective implementation of these policies 5) Monitor the policies Office of Minority Health CLAS Standards 4-7: Standard 4) Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services at no cost to each patient/consumer with LEP at all points of contact, in a timely manner during all hours of operation. Standard 5) Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance. Standard 6) Health care organizations must assure the competence of language assistance provided to LEP patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). Standard 7) Health care organizations must make available easily understood patient related materials and post signage in the languages of the commonly encountered groups or groups represented in the services area. n

6 effective health care in your patients languages...continued from page 9 and training of staff, as well as hospital management, can include cultural competency education and CLAS standards. Compliance is possible. More importantly, to better serve increasingly diverse patient populations, it is necessary and it s the right thing to do. n 1 Margie Akin, Diana Carr, and Peggy Payne, Better Communication, Better Care: Provider Tools to Care for Diverse Populations (Notes from the Health Industry Collaboration Effort s Cultural and Linguistic Workshop, September 2004). 2 Title VI of the Civil Rights Act of 1964 U.S.C. 2000d et. seq. and its implementing regulation at 45 CFR Part 80. Federal Register, 65(169), Aug. 30, U.S. Department of Health and Human Services, Office of Civil Rights, Guidance to Federal Financial Assistance Recipients Regarding Title VI, Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons, Federal Register, 69(7), (last revised October 2006), see (Accessed March 1, 2007) 4 Carmen J. Beamon, et al., A Guide to Incorporating Cultural Competency into Health Professionals Education and Training (Prepared for the National Health Law Program, March 2006). 5 Office of Minority Health, U.S. Department of Health and Human Services, National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. Federal Register, 65(247), (2000). See (Accessed March 1, 2007). 6 Paul M. Schyve, Hospitals, Language, and Culture: A Snapshot of the Nation (with the Joint Commission on Accreditation of Health care Organizations, 2002). 7 Dirk G. Schroeder, Limited English Proficiency (LEP) Regulations: Implications and Guidelines for U.S. Hospitals Serving Minority Populations. (June 2002). 8 From OCR s Policy Guidance on Title VI. See footnote 3. 9 Hospital Language Services for Patients with Limited English Proficiency: Results from a National Survey (sponsored by the Health Research and Education Trust and the National Health Law Program, October 2006). 10Glenn Flores, Language Barriers to Health Care in the United States, New England Journal of Medicine 355, no. 3 (July 20, 2006): To learn more about the CCHCP s Medical Interpreter Training Program, see (Accessed March 1, 2007) 12 CyraCom Language Index (tracked and compiled by CyraCom, 2006). 13Mara Youdelman and Jane Perkins, Providing Language Interpretation Services in Health Care Settings: Examples from the Field (by the National Health Law Program for The Commonwealth Fund, May 2002). 14Dennis Andrulis, Nanette Goodman, and Carol Pryor, What a Difference an Interpreter Can Make: Health Care Experiences of Uninsured with Limited English Proficiency (by The Access Project, April 2002). 13