Effective Communication Promotes Optimal Safety for LEP Patients

According to the Joint Commission, breakdowns in communication cause approximately 80 percent of all medical errors. Although this is a daunting number, those with limited English proficiency (LEP) are more prone to patient safety events than English-speaking patients. These events tend to be more severe and are more often attributed to communication errors. With more than 25 million people in the U.S. being LEP (approximately 8 percent of the population), the need to address the communication needs of LEP patients and their families is paramount.

Accommodating these communication needs is mandated by law, initially with the Civil Rights Act of 1964 and the Americans with Disabilities Act of 1990, and most recently with Section 1557 of the Affordable Care Act of 2010. Moreover, the Department of Health and Human Service's national CLAS (culturally and linguistically appropriate services) standards are in place to advance health equity and eliminate healthcare disparities. The CLAS standards not only direct organizations to offer language assistance (such as interpreter services) to LEP individuals, but also emphasize the importance that those providing language assistance are qualified to do so.

Risking Medical Errors

Unfortunately, too many untrained individuals do attempt to provide language assistance, particularly with interpreting (defined as acting as a third party to facilitate a conversation between patient and provider). In fact, the Agency for Healthcare Research and Quality (AHRQ) has found that there are three primary scenarios that lead to medical errors impacting LEP patients:

Scenario #1: Accompanying adults, such as friends or family members, acting as interpreters for patients

Although friends and family members may be bilingual, being bilingual is not the same as being an interpreter. Professional interpreters are trained individuals with a specialized skill set. Although friends and family members may mean well and are eager to help, several factors inhibit their abilities to interpret effectively:

1. Lack of knowledge about medical issues and medical terminology
2. Hesitancy to relay information (or the tendency to sugarcoat information) about sensitive issues, perhaps due to cultural issues
3. Not enough familiarity with the English language themselves to understand and communicate complicated information
4. Emotional investment that adversely impacts their abilities to be impartial

Scenario #2: Staff who feel they can "get by" with their own limited skills or tools that are not completely accurate

This could be a slippery slope, as a couple of years of taking a targeted language in school does not make an individual proficient enough in the language to be an effective interpreter. In fact, relying on limited bilingual skills could be likened to "knowing just enough to be dangerous.” Similarly, reliance on machine translation tools such as Google Translate is discouraged. Google Translate is not a secure platform; thus, inputting protected health information (PHI) with the use of the Google Translate tool could pose issues with HIPAA. Additionally, Google Translate is not always accurate and should not be trusted for medical conversations. And although machine translation programs are becoming more sophisticated, one minor glitch in communication via a wrongly interpreted phrase can lead to medical errors.

Scenario #3: Cultural issues that are unknown to healthcare staff

For instance, individuals in many cultures may perceive a power differential between healthcare providers and themselves. As such, patients may nod out of deference to healthcare staff, but staff may perceive that nod to be the patient's confirmation that they understand their treatment plan or discharge instructions (when in fact, they don't).

What Can You Do?

Ensure that LEP patients know that they have the right to a professional medical interpreter

Taglines that communicate this message are available in many different languages from the Department of Health and Human Services.

Rely on professional medical interpreters to communicate with LEP patients

Even if patients may speak some English, it is best to employ interpreter services to ensure optimal communication. Professional medical interpreters are specially trained. They possess superior concentration and memorization skills and are familiar with how to best interpret medical terminology. Furthermore, they are neutral third parties who can convey information in a less biased way. Although some larger hospitals and practices employ full-time interpreters who can assist onsite, remote interpreter services—accessed via telephone or video—are available from numerous language vendors.

Recognize and respect the interpreter as part of the patient's care team

You are not only relying on the interpreter to convey words, but also to act as a cultural broker to detect cultural misunderstandings that could impede care. To facilitate seamless interpretation, ask one question at a time, avoid slang or jargon, and speak in complete sentences. Also, do not make the interpreter accountable for what a patient might or might not say, as the interpreter is the medium—not the source—of the message.

If an LEP patient refuses interpreter services, document it

Often LEP individuals may waive their right to a professional medical interpreter and instead request accompanying adults to assist. Be sure to reiterate to these patients that they have a right to a professional interpreter free of charge. If patients insist on using friends or family, then document it. One of the proposed changes to Section 1557 of the Affordable Care Act is that LEP patients' requests to use accompanying adults must be documented. Additionally, consent by the accompanying adults to act as an interpreter should also be documented, and use of the accompanying adult should be appropriate under the circumstances. Do not use minors in any way to interpret except in emergencies where patients risk imminent harm.

In an increasingly diverse society, the demand for language services that include interpreter services is certain to increase. Anticipating this need and addressing it in a proactive way constitutes a forward step in ensuring safe and high-quality care for LEP patients.

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References/Resources

Joint Commission Confronts Deadly Miscommunications: Healthcare IT News

Improving Patient Safety Systems for Patients With Limited English Proficiency: Agency for Healthcare Research and Quality (AHRQ)

Fact Sheet: Nondiscrimination in Health Programs and Activities Proposed Rule Section 1557 of the Affordable Care Act: U.S. Department of Health & Human Services

National Culturally and Linguistically Appropriate Services Standards (CLAS): Department of Health & Human Services

Translated Resources for Covered Entities: U.S. Department of Health & Human Services

Use of Google Translate in Medical Communication: Evaluation of Accuracy: BMJ Publishing Group Ltd

How the Proposed Changes to Section 1557 Affect Individuals with Limited English proficiency (LEP): National Health Law Program