Members of the healthcare team within their professional scope of practice.

Transcription

1 TITLE Guide to Interpreter Services NUMBER NH-RE-RI-300 Jun 08 JCAHO FUNCTIONS APPLIES TO I. SCOPE / PURPOSE RI, TX, PF Novant Health facilities The purpose of this policy is to promote consistency in our communication with patients and to ensure the same level of care for all patients. Novant Health facilities strive to provide effective communication to patients in a language they can understand while protecting their rights. This includes sign language for the deaf and hard of hearing, as well as foreign language interpreters. Interpreter services are provided at no charge to the patient. Patients may refuse interpreters provided by the facility; such refusal will be documented in the medical record. Note: For a comprehensive review of communication aids, refer to the NH policy Communication Needs of Patients and Families. II. POLICY A. Patients will be offered and provided interpreter services, as appropriate, at no cost to the patient and/or family. B. Patient's rights will be protected. C. Patients will have the right to refuse interpreter services when offered. III. QUALIFIED PERSONNEL Members of the healthcare team within their professional scope of practice. IV. EQUIPMENT N/A V. PROCEDURE The procedure serves as a guideline to assist personnel in accomplishing the goals of the policy. While following these procedural guidelines personnel are expected to exercise judgment within their scope of practice and/or job responsibilities. A. Identify the language needed. Refer to the Language Identification Card (Addendum A) on the Communication Aids Matrix of the NH Intranet, if needed. This card identifies the most frequently needed languages in the United States. B. Evaluate the Level of Interpretation required: Purpose: The need for interpreting services will be addressed based on the level of complexity and the expertise of the interpreter. In all cases, patient rights will be protected. When indicated, the services of an interpreter will be offered. The patient may choose to decline the offered interpreter services. Services will be offered, as appropriate, even if a bilingual friend or family POLICY/PROCEDURE: Guide to Interpreter Services Page 1 of 9

2 member accompanying the patient is available to interpret. Family and friends may be used for basic interpreting upon the request of the patient. It is recommended that children, under the age of 18, not be used for medical interpreting. LEVEL I DESCRIPTION: PERSONNEL: LEVEL II DESCRIPTION: PERSONNEL: LEVEL III DESCRIPTION: PERSONNEL: CUSTOMER RELATIONS Provide simple non-medical interpreting to assure positive customer relations. Includes services such as giving directions, assisting with telephone calls, translating the food menu, orientation to the patient s room and department locations. Interpreters by telephone (dual-receiver telephones are available at FMC only), Facility Interpreters, Professional Facility Interpreters and family members or friends at the request of the patient. BASIC MEDICAL COMMUNICATION Involves gathering information from clients. Includes services such as a simple history, reading pre-translated facility forms or admission forms, or reading informed consent forms for treatment if no medical explanation is needed. A speaker phone is available when needed from Plant Engineering (SPR) or Telecommunications (NHTR). Interpreters by telephone (dual-receiver telephones are available at FMC only), facility interpreters, Professional Facility Interpreters and family members or friends at the request of the patient. MEDICAL COUNSELING AND TEACHING Provides for complex, sensitive medical interpreting. Includes services such as gathering an in-depth history, discussing the treatment plan, imparting sensitive information on end of life issues, reproductive issues, mental health, obtaining informed consent when the medical plan must be explained, discharge instructions/teaching, translation of medical documents, and patient teaching materials. A speaker phone is available when needed from Plant Engineering (SPR) or Telecommunication (NHTR). Contract On-site Interpreters, Interpreters by Telephone (dual-receiver telephones are available at FMC only), Facility Interpreters (limited to Professional Clinicians including RN, MD, Physical Therapist, Pharmacist, Respiratory Therapist) and Professional Facility Interpreters. Because of the sensitive nature of the information that is being translated, it is not a good idea to use family members or friends for this type of interpretation. However, the patient has the right to request that the translation be performed by a family member or friend in all situations. If a patient insists on having a family member or friend provide translation, the health care provider shall document in the patient s chart that an interpreter was offered and refused. C. Available resources - Based on the level required, utilize the most appropriate resource. The following are the mechanisms to procure the currently available modes of interpretation. 1. Professional Facility Interpreter-Spanish interpreters provide interpreter, translation, and guest relation services. -Spanish Interpreters Are available 24 hours a day, and may also POLICY/PROCEDURE: Guide to Interpreter Services Page 2 of 9

3 provide telephone interpreter services for other Novant Health facilities. Interpreters may be contacted by cell phone or pager and may also provide telephone interpreter services for other Novant Health facilities as time permits. They are listed on the Communication Aids Matrix on the NH Intranet 2. American Sign Language Interpreters If the patient/family member needs an American sign language interpreter, refer to the Communication Aids Matrix on the NH intranet. 3. Non-professional facility interpreters - SPR ONLY: A resource for interpretation is our own staff and physicians. To find these individuals, locate an Office Automation terminal and follow these steps after logging on: a) Go to the Intranet b) On the Navigation Bar (left), click on Directories; or, click on Communication Aids SPR, under Popular Sites (Scroll down the matrix until you see Internal Interpreters; Click on Internal Interpreters). Or click on Communication Aids under Directories on the Nursing/Dept. HomePage. c) Click on NHSP (Novant Health Southern Piedmont) d) Click on Interpreters e) Click on Internal f) Then search for the language you need. Languages are listed alphabetically with Sign Language listed under S. Information included in the listings is as follows: (1) Language name (2) Employee name (3) Telephone number (4) Department and location (5) Normally scheduled shift (6) Weekend availability (if applicable) g) Contact the employee to ascertain availability to provide interpretation 4. Interpreters by Telephone - Interpreters by telephone are available for all languages and Spanish, when the Professional Hospital Interpreters are not available. For more information, refer to the Communication Aids Matrix on the NH intranet. 5. On-Site Interpreters - On-site interpreters are available for all languages, when the Professional Hospital Interpreters are not available. For more information, refer to the Communication Aids Matrix on the NH intranet. D. Interpretation expenses - Costs related to interpreters by telephone and onsite interpreters are covered by the Interpreter Services Department Staff are directed to forward all SPR invoices, for interpretation, to Interpreter Services Department Staff. For FMC locations/facilities, invoices will be directed to FMC Patient Relations Department. All other non-fmc locations/facilities will be responsible for costs incurred for interpretation services used. VI. DOCUMENTATION POLICY/PROCEDURE: Guide to Interpreter Services Page 3 of 9

4 A. Documentation is found in the medical record corresponding to the service/activity provided in which an interpreter was needed. B. Documentation, as appropriate, includes, but is not limited to: 1. Interpreter offered 2. Interpreter refused 3. Name of person/ service used 4. Service/ activity associated with use of the interpreter C. Interpreters do not make entries into the medical record unless they are professional staff with charting privileges who would otherwise make medical record entries. Professional staff who request interpreter services should document the services provided as outlined in VI. VI-B-1. VII. DEFINITIONS A. Contract On-Site Interpreters Interpreters provided through an agreement with a professional interpreter service to provide interpreter services on facility premises. B. Facility Interpreter - Current hospital employee or physician willing/knowledgeable to provide interpretation who provides such service in conjunction with his or her current job role. A complete, up-to-date listing of facility interpreters is posted on the NH intranet C. Interpreter A person who provides oral or visual communication services between two languages. D. Interpreters by Telephone - Use of an outside agency, with staff specifically trained in medical interpreting, available 24 hours a day/7 days per week in which the interpretation is done by telephone. E. Interpretation the act of listening to something in one language and orally transmitting it into another language. F. Limited English proficient individual ( LEP ) Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak or understand English may be limited English proficient, or LEP, and may be eligible to receive language assistance with respect to a particular type of service, benefit or encounter. G. Professional Facility Interpreter An employee whose primary role is to provide interpretation and translation services. H. Translation the replacement of written text from one language into an equivalent written text in another language. I. Translator A person who converts a document, written in English, into another language in written form. VIII. RELATED DOCUMENTS NH Communication Needs of Patients and Families NH Patient Bill of Rights and Responsibilities IX. REFERENCES 42 C.F.R. Section USCA Ch. 21, Subch. V., Section 2000d-1, 2, 4a POLICY/PROCEDURE: Guide to Interpreter Services Page 4 of 9

5 CFR T.45. Subt. A., Subch. A, Pt. 80 Executive Order No (June 23, 2000) 65 FR Executive Order No (August 11, 2000) 65 FR X. SUBMITTED BY Communication Services sub-team of the Patient Rights and Organizational Ethics Functional Team (SPR) Patient Rights Team (NHTR) Melissa Phipps, Assistant General Counsel XI. KEY WORDS Language, interpreter, communication, language identification card, translator, translation, communication aids matrix, patient rights, ESL, foreigner, American Sign Language, ASL, sign language, foreign language, Limited English proficient, Limited English proficiency XII. INITIAL EFFECTIVE DATE Mar 1999, June, 2003 DATE REVISED May 1999, May 2000, Apr 2001, Jun 2002, Aug 2002, Apr 2003, Nov. 2004, May 2005 DATE REVIEWED June 2008 POLICY/PROCEDURE: Guide to Interpreter Services Page 5 of 9

6 SIGNATURE SHEET (one copy only to be maintained by author) Company / Facility(s) Department Title Action All Novant Health Facilities All Guide to Interpreter Services reviewed APPROVED BY: Title Approved By Signature Date COO, TR Sallye Liner 5/28/08 President, CEO, SPR Carl Armato 5/5/08 COMMITTEES APPROVED BY: Committee Chairperson/Designee Date Corporate Patient Rights Reba Teeter / Hunter Roddey April 28, 2008 Committee DATES OF APPROVAL: Date Revised/Reviewed June 2008 Date Due for Next Review June 2011 POLICY/PROCEDURE: Guide to Interpreter Services Page 6 of 9

7 ADDENDUM A POLICY/PROCEDURE: Guide to Interpreter Services Page 7 of 9

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9 Presbyterian Healthcare access code is POLICY/PROCEDURE: Guide to Interpreter Services Page 9 of 9