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LEP Cultural Competency [Event Recap + Q&A]

LEP cultural competency

The Quality Interactions webinar, "When Language Barriers Lead to Poor Patient Care (And What to Do About It)," provides information and care tips for successfully working with interpreters to deliver high-quality healthcare to patients with Limited English Proficiency (LEP)

Watch Full Video Presentation

A Case for Improving Care

In the webinar presentation, Dr. Alexander Green, a QI co-founder and expert in culturally competent care, provides data showing why improving healthcare services for the 25 million people in the US with LEP is so important. For example, patients with LEP receive less preventive care, have worse control of chronic conditions, and are less likely to understand their disease and treatment plans than individuals without LEP. Patients with LEP are also:

  • More frequently and severely affected by adverse events
  • More likely to experience medical errors due to poor communication
  • More likely to suffer from physical harm when errors occur

This elevated risk comes primarily from communication problems arising from language barriers and cultural factors.

Communication Problems

Common Causes of Communication Problems with Patients with LEP

Many organizations and individual practitioners rely on ad hoc interpreters, or untrained people who are interpreting on the fly, to help communicate with patients with LEP. Examples of ad hoc interpreters include: 

  • A family member
  • A bilingual staff member pulled away from other duties to interpret
  • A self-declared bilingual in a hospital waiting room who volunteers to interpret
  • An advanced language student

Dr. Green shows that ad hoc interpreters should only be used in emergencies when there is no time to arrange for a trained medical interpreter. Individuals who lack experience translating medical terminology can exacerbate communication problems and create confusion. Furthermore, there are ethical reasons to avoid involving family members—and it is illegal to ask a minor to interpret except in emergency situations. 

Working with Medical Interpreters

Joint Commission and DHHS regulations mandate that hospitals offer medical interpreters at no cost to the patient. Failure to do so can cost the organization its accreditation or federal funding. Whether working in person, over the phone, or on video, medical interpreters ensure the patient gets the best quality of care. Interpreter functions include: 
  • Convert the message
  • Clarify the message
  • Clarify cultural nuances
  • Expanded role as patient advocates, safety monitors, and navigators

Role of Interpreter

If a patient or the patient's family is resistant to using an interpreter, Dr. Green recommends respectfully asserting the need for professional medical interpretation. For example:

“Even though you do speak English, I need to make sure that there are no miscommunications or mistakes made.”

“Even though your family member wants to interpret, professional interpreters are trained to understand medical terminology ensure that we don’t miss anything important.”

“This is the policy of the clinic/hospital/practice.”

Dr. Green's 5 Tips for Working with Medical Interpreters

  1. Prepare for the encounter - ideally, meet briefly with the interpreter to go over the patient's history and goals for the interaction
  2. Set the stage - if in person, arrange the chairs in a triangle shape so everyone can make eye contact
  3. Keep it simple - avoid medical jargon and use short sentences
  4. Pay attention to nonverbal cues - watch your patient for body language and tone
  5. Debrief and document - discuss the interaction with the interpreter afterward and ask for clarification if necessary

Questions & Answers

Many participants in the webinar had specific questions about improving care for patients with LEP. In this blog post, Dr. Green responds to the questions he didn't have time to address during the live presentation.

1. What tools or metrics do you use to measure the effectiveness of your language access program?

The Quality Interactions course, Ensuring High Quality Care for Individuals with Limited English Proficiency, includes a pre- and post-test to assess knowledge gains, in addition to an evaluation that seeks participant feedback about quality and usefulness of the learning experience.

2. Are you aware of medical interpreters who are also trained/credentialed/experienced Community Health Workers? 

Yes, there has been a small but potent movement towards engaging interpreters to do more than interpret and, in fact, engage as integral members of the health care team for patients with LEP. At the Family Health Center of Worcester (a federally-qualified community health center in Massachusetts where I provide care), all interpreters are co-trained and certified as both interpreters and health navigators/CHWs. This has been a very effective model of care in a place with a large proportion of patients with LEP who need more help managing their interactions with the health care system and beyond than just the interpretation that takes place during the clinical visit. 

3. Do you have any suggestions for interpreters in a 911 setting, such as the back of an ambulance?

I would recommend using a telephonic interpreter service via a cell phone. Reputable organizations include Language Link, Cyracom, and Language Line.

4. If clinicians have passed a language proficiency test, can they communicate with patients without having an interpreter present? 

Yes, there are certification tests for healthcare professionals. This option may be even more effective than interpreter services if the healthcare professional is proficient and comfortable in the second language.

5. Interpreters for indigenous Mexican languages and some South Pacific languages are hard to find in Oregon. Are there any organizations that connect us with overseas companies that may offer these options we do not have in the US? 

Although we don't have firsthand experience using it, the interpreter service Jeenie may be an option for working with indigenous language interpreters.

6. Beyond education, what is the best way to encourage providers to use interpreters and document their use in patient charts?

Make it mandatory and do periodic reviews with feedback privately to each healthcare professional and anonymously as a group so teams can work together towards improving their rate of interpreter engagement in encounters with patients with LEP. The periodic surveys by the Joint Commission survey is an excellent way to get this started as part of improving quality and safety—but don't wait if it is too far in the future. 

7. Do you consider it appropriate for bilingual staff to communicate with the patient in their shared language without the use of an interpreter? 

Yes, but it must be clear that the healthcare professionals are fluent in the non-English language.

8. For virtual interpreters, are there regulation/processes to provide written instructions for aftercare? I noticed at a recent visit all paperwork was provided in English. Also, no recordings were available for replay if family members were not present at the time of interpretation.

Unfortunately, the lack of a recording would be the case in almost all healthcare interactions, with or without an interpreter. Written instructions are supposed to help, but as you mention, they are not always offered in the patient's preferred language. I have not heard of these being translated, but it is an important area to look into and another extended role for professional medical interpreters. When interpreters are also trained as health navigators, they are expected to follow up with patients by phone and sometimes in person to help them understand the next steps in their care, but this is still not widespread.

9. Could providers lose their license to practice for refusing to use medical interpreters and instead "getting by" with their limited proficiency in the target language?

It's very possible. There have been several high-profile lawsuits related to language barriers and lack of effective communication leading to a terrible outcome. I would imagine that in addition to being sued financially, some providers may have also faced disciplinary actions from their medical boards.

10. How would you recommend improving healthcare interpreter services for areas that don't have many readily available qualified interpreters? For example, rural areas.

Ideally, multiple organizations could pool resources to set up remote interpreter banks, perhaps in the largest physical site, which can serve as both local and telephonic or video-based interpreters for other smaller sites in the area. 

11. How does MGH [Massachusetts General Hospital] ensure that qualified interpreters are used for LEP patients? What processes and systems do you have in place?

At MGH, the director of interpreter services interviews and screens interpreters, and they must be certified by one of the major certifying boards, such as the National Board for Certification of Medical Interpreters.

Watch the full video recording of Dr. Green's presentation on improving care for patients with LEP.

Watch Full Video Presentation

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