COMMUNICATION ASSISTANCE

of 8 Values Context: Practicing within the context of our core values of Dignity, Excellence, Service and Justice ensures the provision of respect for each person, accountability, commitment to quality, opportunities to serve each other and a sense of community among all persons. Background: We respect the right and need of patients for effective communication. We serve a significant population of limited English proficient (LEP) patients as well as hearing, speech or vision impaired patients. For the purpose of this policy, all references to patient will include the patient s family representative and/or surrogate decision-maker. It is essential to the provision of safe and quality patient care that Queen of the Valley Medical Center (QVMC) ensures that patients with language or communication needs can effectively provide Medical Center staff with a clear statement of their medical condition and history, and understand the provider s assessment of their medical condition and treatment options. A patient is considered to have a language or communication barrier if 1) the patient is a member of a group of non-english speaking or LEP individuals which constitutes at least 5% of the patients served by QVMC, or 2) the patient is hearing/speech impaired, and the primary language is sign language or 3) vision impaired. The most frequently encountered language other than English at QVMC is Spanish. Purpose: To ensure that all Limited English Proficiency (LEP) patients as well as patients with hearing, speech, or vision impairments are able to understand their medical conditions and treatment options. To ensure that staff members are able to provide quality patient care to said patients. Policy: QVMC prioritizes careful attention to effective communication during the provision of medical, nursing and ancillary services where patient safety, medical error and ability to understand treatment options are affected. The following situations will require the use of an interpreter, but are not limited to: Provision of clinic and emergency medical services; admissions, obtaining medical histories; explaining any diagnosis and plan for medical treatment; discussing any mental health issues or concerns; explaining any change in regime or condition; explaining any medical procedures, tests or surgical interventions; explaining patient rights and responsibilities; explaining the use of seclusion or restraints; obtaining informed consent; providing medication instructions and explanation of potential side effects; explaining discharge plans and

of 8 instructions; discussing issues at patient and family care conferences and/or health education sessions; discussing Advanced Directives; discussing end of life decisions; and obtaining financial and insurance information. 1. Use of Interpreters: Staff utilizing interpreting services shall conduct themselves as if they were working with an English-speaking patient, performing all the functions normally done for or with such patients. Staff members must be present to answer any questions that patients may have. Staff may not delegate admission, education, instructions or any other part of their job to the Interpreter. 2. Consent and discharge: Consent and discharge instructions must be in English as well as the primary language of the patient, for all populations which comprise at least 5% of QVMC s patient population. 3. Translation Services: All vital QVMC documents such as consent forms, discharge instructions, applications, written correspondence, written notices, and other outreach materials must be translated into the non-english language of any LEP group that comprises at least 5% of the QVMC s population. When documents are not translated, a sight translation should be requested. Definition of Terms: Hearing Impairment: Hearing loss that prevents a person from totally receiving sounds through the ear. If the loss is mild, the person has difficulty hearing faint or distant speech. A person with this degree of hearing impairment may use a hearing aid to amplify sounds. If the hearing loss is severe, the person may not be able to distinguish any sounds. Interpreter: One who has been hired to interpret as well as 1) trained in healthcare interpreting, 2) adheres to the standards and protocols of this profession, 3) has an advanced knowledge of medical terminology, and 4) can accurately and completely render communication from one language to another. Interpreters have been tested for their proficiency in the language in which they interpret and assessed for their interpretation skills. Interpreting: Oral rendering of one language into a second language and vice versa to facilitate the exchange of communication between two or more persons speaking different languages. Limited English Proficient (LEP): An individual who does not speak English as his/her primary language and who is unable to, read, write, or understand English at a level that permits him/her to interact effectively with health care professionals.

of 8 Qualified Bilingual Staff (QBS): A bilingual QVMC employee who has been assessed according to the established procedure / process for language proficiency, medical terminology and Fundamentals of Healthcare Interpreting. With the approval of their department managers, the QBS s may assist the healthcare providers with interpreting (oral interpretation, not written translations) in their departments. Sign Language: A visual language that uses manual communication instead of sound to convey meaning by simultaneously combining hand shapes, orientation and movement of the hands, arms or body, and facial expressions to express fluidly a speaker s thoughts. Sign language is not universal and each country in the world has its own sign language. Sign Language Interpreter: A person who can interpret the meaning of spoken words into sign language as the words are spoken and interprets sign language messages into spoken language as they are signed (e.g., American Sign Language). Sight Translation: A verbal rendering of a written document into the target language. (Note: Sight translations will be limited to brief texts that cannot be translated due to practical or time constraints). Threshold Language: The language of a substantial number of non-english-speaking people defined as 5% or more of the people served by QVMC. In the case of Medi-Cal recipients, a threshold language is identified on the Medical Eligibility Data System (MEDS) as the primary language of 3,000 beneficiaries or 5% of the beneficiary population, whichever is lower, in an identified geographic area, per Title 9, CCR, Section 1810.410 (f) (3). Translation: Conversion of a written text into a written text in a second language corresponding to and equivalent in meaning to the text in the first language. Translator: A person who converts the written text from one language into text with an equivalent meaning in a second language. Vision Impairment (including blindness): Vision loss, to such a degree that it cannot be corrected by conventional means. Considerations/Regulations/Related Issues: The Joint Commission (TJC) Section RI.01.01.03 (2014) Title VI of the Americans with Disabilities Act Title VI of the Civil Rights Acts of 1964, 42 U.S.C. 2000d.

of 8 Executive Order 13166 Kopp Act CA Health and Safety Code, Section 1259 (1990) CA Government Code Section 11135 CCR, Title 9, Section 1810.410 (f) (3) California Standards for Healthcare Interpreters: Ethical Principles, Protocols, and Guidance on Roles & Intervention, 2002 Scope/Responsible Person(s): All QVMC Employees Interpreting Services: QVMC offers several resources to provide interpreting services. Providers of interpreting services include: 1. Interpreting Services Department Staff 2. Qualified Bilingual Staff (Spanish/English). 3. Pacific Interpreters (contracted telephone interpreters) 4. Language People (contracted interpreters for sign and other foreign languages) Methods for Provision of Interpreting Services: Acceptable methods for the provision of interpreting services are the following: In-person interpreting Telephone based interpreting Mechanisms for the provision of interpreting services are available to all clinical (inpatient and outpatient) areas of QVMC during the hours of operation. Procedure for Obtaining an Interpreter: All QVMC employees seeking interpreting services for patients requiring language assistance use the following procedures: 1. Spanish Speaking Patients Contact the Interpreting Services Office, at ext. 4094, or by dialing the operator. When in-person interpreting services are not available, staff may contact Pacific Interpreters at 1-800-264-1552 (access code: 830295) for assistance, 24 hours a day, every day. Pacific Interpreters is a telephonic interpreter resource for all languages. Designated dual handset telephones are available in all patient care areas and are to be used when calling Pacific Interpreters.

of 8 2. Non-English Speaking Patients other than Spanish A. To accommodate patients needing interpreting services other than Spanish, call Pacific Interpreters at 1-800-264-1552 (access code: 830295) for assistance. In some cases, a contracted interpreter may be available in person for language interpretation other than Spanish. This service requires at least 24 hours notice and can be arranged through Interpreting Services, ext. 4094. 3. Hearing/Speech Impaired Patients A. To accommodate hearing/speech impaired patients needing Sign Language for communication, contact Interpreting Services at ext. 4094. If they are not available, call the Nursing Supervisor for assistance. B. The Emergency Department has a TDD which hearing impaired patients can call in at (707) 265-8222. The staff also has a stand-alone, text based communication device (UbiDuo) available. Hearing impaired patients may reach the QVMC, operator at (707) 226-2901 for general information. C. Other communication aids, such as sound amplifiers and portable telephone amplifiers, are available to hearing/speech impaired patients by contacting Interpreting Services Department at ext. 4094. If written communication is utilized for the hearing-impaired patient, while waiting for the interpreter to arrive, all of the written communication must be kept in the patient s medical record. 4. Vision Impaired Patients The Admitting Office keeps a Braille version of vital documents such as informed consents and Patient s Rights in their office and makes them available to patients. 5. Telephonic Interpreting: Pacific Interpreters Contact Pacific Interpreters when an in-person interpreter is not available. Interpretation is available in more than 200 languages, 24 hours a day, every day. A. Dial 1-800-264-1552. B. Follow the prompt to choose language needed. C. Provide the Access Code: 830295. D. The telephonic interpreter will provide his/her ID number, which must be recorded in the

of 8 patient s medical record. E. Pacific Interpreters is available for a three-way call, if staff needs to communicate with a patient at another location. Required Documentation for Staff When Using Interpreter: When it is necessary to utilize an interpreter, staff is required to document in the patient s electronic medical record the interaction, including the following: Name of the person who acted as the interpreter (or title), or ID number when using Pacific Interpreters Informed Consents: When an in-person interpreter is used, he or she will sign the Consent form where indicated. For telephone interpreters, record the interpreter s ID number. A patient may, after being informed of the availability of interpreting services, choose to use a family member or friend, instead. If that is the case, record patient s choice in the electronic medical record with an explanation for the decision. Children under the age of eighteen (18) must not be used to interpret. It is recommended that an interpreter be present during the provision of medical, nursing and ancillary services. Staff cannot ask patients to bring in their own interpreter for medical encounters. Patient Language Tracking: The patient s language preference and/or need for interpreting services are identified and recorded in the electronic patient care system during the registration process. This information is available to all staff on the patient s face sheet. Procedure to Inform Patients of their Right to Have Interpreting Services: LEP and hearing, speech or vision impaired patients will be advised of their right to have interpreting services and/or Braille forms provided to them at no charge within a reasonable time. Emergency medical services will not be withheld pending the arrival of an interpreter. Contact names, numbers and access codes for direct access to interpreting services are available to staff. It is recommended that an interpreter be present during the provision of medical, nursing and ancillary services. Public Notice: Notices in English and Spanish regarding the availability of free interpreters are posted in key locations. These notices advise patients of the procedure for obtaining an interpreter at no cost to them, a TDD number for the hearing impaired, and the telephone numbers where complaints may be filed. Notices are posted in the Emergency Department, the Admitting/Lobby area, and in outpatient treatment areas.

of 8 Availability of Devices to Aid Communication Assistance Clinical areas are equipped with devices/dual handset telephones for the delivery of remote interpreting. Service areas which need access to this type of service include but are not limited to: 1. All stations of patient registration, financial counseling and admission. 2. Designated exam rooms. 3. All nursing stations. 4. All telephone based services developed for public access, including hospital operators and appointment scheduling. Other communication aids, such as sound amplifiers and portable telephone amplifiers and TDD s, are available to hearing/speech impaired patients by contacting the Interpreting Services Department at ext. 4094. Orientation/Education of Employees: A. During new employee orientation, employees are informed of QVMC s commitment to provide interpreting services for patients in their primary language, when communication in English is not possible or advisable, and the procedures necessary to achieve it. B. Ongoing education will be provided to employees as deemed necessary. C. Employees interested in becoming a Qualified Bilingual Staff (Spanish/English) must be in good standing and will require prior approval from their manager. They must meet the following criteria: 1) be fluent in Spanish and English, 2) complete the Fundamentals of Healthcare Interpreting, and 3) successfully pass the IST (Interpreter Skills Test) or MCT (Medical Certification Test) administered by Language Line Academy. Ongoing Assessment of This Policy: In compliance with the Kopp Act, California Health and Safety Code Section 1259, this policy is reviewed annually by this facility and submitted annually to: State Department of Health Services Office of Civil Rights, MS 0504 P.O. Box 997377 Sacramento, CA 95899 (916) 445-0938 References: Office of Minority Health, U.S. Department of Health and Human Services National Standards on Culturally

of 8 and Linguistically Appropriate Services (CLAS) in Health Care, 65 Federal Register 80865 Culturally and Linguistically Appropriate Services (CLAS) Standards in Health Care (2000) Dymally-Alatorre Bilingual Services Act 1973 Medi-Cal Managed Care Cultural & Linguistic Requirements (1998) Roadmap for Hospitals (The Joint Commission) (2010) Resource Person s Job Title: Interpreting Services Staff Nursing Supervisors Pacific Interpreters Author s Job Title: Manager, Interpreting Services Committee Approvals: Organizational Ethics and Values Committee: 1/02, 11/04, 2/09, 2/10, 6/10, 5/11, 8/13, 10/14, 10/15 Patient Care Services Collaborative Practice Council: 3/99, 4/01, 2/02, 11/04 (replaced by SRC) Survey Readiness Committee: 4/07; 6/07; 2/09; 2/10; 6/10, 5/11, 8/12, 9/13, 10/14, 11/15 Medical Staff Quality Committee: 7/07, 3/09, 4/21/10, 6/16/10, 6/11, 7/11, 8/12, 9/13, 11/14, 11/15 Medical Staff Executive Committee: 8/07, 4/09, 5/4/10, 9/11, Clinical Quality Committee: 8/07, 4/09, 7/10, 9/11, Board of Trustees: 8/07, 4/09, 7/10, 9/11.