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Qualified interpreters improve health literacy and patient safety
For proper use, establish policy and educate staff
To improve health literacy the use of trained interpreters must be common practice when health care practitioners are communicating with patients who are not proficient in English.
"The meaning behind health literacy is the ability for patients to adequately understand their health care and how to comply with treatment plans that are important for their well being. Having an interpreter communicating the self care plan, treatment plan, or simple instructions, such as 'take this pill two times a day,' is key to enhancing health literacy," says Mursal Khaliif, RN, director of Community Health & Language Services at the University of Minnesota Medical Center, Fairview in Minneapolis.
Communication in general is an important element of patient safety, he adds. "When the patient doesn't understand the provider and vise versa patient safety is compromised at many levels," says Khaliif.
For example, getting an accurate medical history in order to determine a diagnosis is not possible when the patient does not speak the provider's language nor can patients be given clear instruction for disease management. When patients with diabetes do not understand how to administer insulin or monitor their blood glucose level they often end up in the emergency department, explains Khaliif.
If a qualified medical interpreter is not used when communicating with limited English proficient patients the result could be a misdiagnosis, says Jose Sanchez, coordinator of Interpreting and Translating Services at Children's Healthcare of Atlanta.
According to Sanchez there are a lot of risks involved when a person is not familiar with the medical terminology and steps into the role of interpreter.
Good interpretation and cultural competency has a positive impact on patient safety, says Boris Kalanj, MSW, LISW, director of Cross Cultural Care and Interpreter Services at Children's Hospitals and Clinics of Minnesota in Minneapolis.
"Most of patient safety hinges on the patient understanding what is going on at all levels and all points of care. If there is any misunderstanding there is more potential for unsafe care," he explains.
When Kalanj was hired six years ago interpreters were often seen by health care professionals as voice boxes, machines or tools.
"I wanted the organization to see interpreters as cultural resources, people who are steeped in two different cultures and can therefore build bridges," says Kalanj.
The department has mushroomed growing from a staff of four people to 24 full time employees as the number of interpreted interactions rise. In six years interpreted encounters have grown from 5,000 to 40,000 annually.
Children's Hospitals and Clinics are not alone in this growth. About 80 interpreter encounters are completed each day at Clarian Health in Indianapolis, IN, according to Molly K. Smith, manager of Language Services.
With the need for interpreter services increasing it is important for institutions to set in place policy and procedure for proper use, says Smith.
Policy will help to ensure the provision of equal access to health care for patients and their families who have limited English proficiency and the use of qualified interpreters rather than family and friends. Sanchez says, "It is important to have a policy because if you don't have structure or guidance there is no way for people to know what your department is committed to."
Securing an interpreter
At most health care institutions the patients preferred language is identified upon registration whether for a clinic appointment, hospital procedure, or on an emergency or labor unit. In this way the need for an interpreter is identified in advance.
At the University of Minnesota Medical Center, Fairview patients are asked, "What language do you prefer to communicate your health care need?" If they mention a language other than English the follow-up question is, "Would you like to use an interpreter?"
In addition the policy states that a health care practitioner can ask for an interpreter even if the patient has not requested one. "Communication is a two way street. Providers and health care practitioners have a right to effective communication with their patients just as much as the patients have a right to that," says Khaliif.
There are some situations where the need for an interpreter is not accurately identified
For example, one parent might speak English and the other struggle with the language, therefore an interpreter is not requested.
"We encourage the family to use an interpreter so better communication can take place even when one of the parents is bilingual. We want to make sure there is effective communication with all members of the family," says Sanchez.
Last minute requests are often an indication that a patient has not been flagged as needing an interpreter when he or she registers, says Laura Rocha Nakazawa, MA, program coordinator for Interpreter Services at Dana-Farber Cancer Institute in Boston, MA.
To remedy this problem the department creates two different listings each day. One is of all the patients who have requested an interpreter and the other is of the patients who have indicated their primary language is not English yet no request for an interpreter has been made. Often these patients have used interpreters in the past. A quick call to the clinic determines whether or not there is a need. Sometimes the patient is just coming in for blood work and doesn't need an interpreter.
In addition, when interpreters are working with a patient at a clinic and he or she makes another appointment they notify interpreter services so there is an early record of the need.
At Dana-Farber the list of scheduled interpreter encounters is completed on a weekly basis. "It is easier to schedule an interpreter beforehand and there is a greater chance we can provide one. We decided to do this to try to control last minute requests," says Nakazawa.
Making sure interpreters are used when needed and scheduled in advance whenever possible takes more than a written policy, it requires staff education.
At Children's Healthcare of Atlanta staff members can find information on interpretive services on their web site and there are instructions on how to access an interpreter posted on various units and in nursing stations.
To make sure interpreters are used for informed consent and written discharge instructions the forms have a place for the interpreter's signature.
During employee orientation at the University of Minnesota Medical Center, Fairview each new hire learns how to access and use interpreters. There is one number to call at any time day or night for an interpreter and their services can also be requested electronically when other services are ordered such as lab work.
"As part of orientation we also make sure folks understand the key situations or encounters where the use of an interpreter is required under our policy," says Khaliif.
These include the diagnosis process, discussion of treatment plans, communicating discharge planning, and providing social services or spiritual services.
In addition to knowing when to use an interpreter it is important for staff to know how, says Kalanj. During employee orientation at Children's Hospitals and Clinics of Minnesota a video is shown titled "Communicating Effectively Through an Interpreter: an Instructional Video for Health Care Providers" produced by the Cross Cultural Health Care Program in Seattle.
In the video there are three scenarios with one showing an interpretive encounter filled with problems, a second showing a good encounter, and the third showing how to correct the problems in the first encounter.
"The idea is that sometimes you will not get a qualified and super competent interpreter yet you as a provider have the responsibility of managing that person to work for you rather than against you or independently," explains Kalanj.
Last year the institution began a cultural competency training program for employed physicians and nurse practitioners that must be completed if they want their year-end bonus.
At Dana-Farber Cancer Institute the staff interpreters are considered part of the care team and not only interpret content but also clarify. For example, when they notice concepts are confusing for a patient they ask the provider to rephrase the information so it is more easily understood.
Also they may explain the peculiarities of a culture in relation to the health system, beliefs, and customs to assist providers in their decisions, says Nakasawa.
"The interpreter can play a role to facilitate the communication to achieve the maximum impact needed for that encounter," she explains.
Creating opportunity for best practice
While each institution sets standards for hiring interpreters good training is not necessarily enough. Kalanj says someone may have a sophisticated command of medical terms in two languages and still not be an ideal interpreter unless they are able to adjust the complexity to the level of the patient.
"Interpreters who have the ability to communicate and read the patient and persist with both parties to get things clarified and taught back if needed to make sure understanding is obtained, those people are the most valuable," says Kalanj.
For staff interpreters people are given screening tests for English and the target language and their ability to interpret is assessed by role playing. However there are so many requests for interpreters at Children's Hospitals and Clinics of Minnesota about 30 to 40% of the encounters are met by outside agencies.
Children's Healthcare of Atlanta requires their interpreters to have a bachelors degree, one year experience interpreting in a medical setting, and training in medical interpreting. Once recommended for hire they must take an extensive test and score 85 percent or better in order to join the staff.
At Clarian Health the interpreters must enroll in a course titled "Bridging the Gap" and complete its requirements, which include a written final exam and clinical evaluations with interpreting sessions.
Dana-Farber Cancer Institute requires all interpreters to have completed a medical interpreter training program. They must have a certificate of completion for one of these courses and also pass a test given by the cancer institute in order to be hired.
Linguistic skills, interpreting skills and training are all screened through a testing process before an interpreter is hired at the University of Minnesota Medical Center, Fairview.
"What is involved in interpreting is the ability to listen to what is said in one language that can be as short as three words or as long as five sentences, understand it, gather the underlying meaning, and then find a way to communicate that meaning all in a matter of seconds," says Khaliif.
All professional interpreters must follow a code of ethics for health care interpreters, adds Khaliif. These provide guidelines in situations when a patient seeks their advice or shares information withheld from the other members of the health care team.
Many barriers to the use of professional interpreters still must be addressed even though institutions are hiring interpreters to have on staff, contracting with outside agencies in their area to fill in the gaps, and using telephone interpreting services for those spur of the moment encounters or when the language is not common in the region.
A common barrier to the use of professional interpreters is taking the time to make the request, states Smith. It is easier to use family and friends, she adds.
Or sometimes practitioners who can speak a little Spanish try to communicate with the patient not realizing their level of understanding is too low to ask all the questions properly, says Nakazawa.
The way to overcome barriers to the use of professional interpreters is by education, says Khaliif. "Educate health care practitioners about the importance of using good, trained professional interpreters," he says. For example, family members cannot always effectively communicate what is being said in a medical situation. In addition they are not objective and impartial and will not alert each party when a situation is not conducive to effective communication.
There are many occasions when the use of an interpreter is needed to ensure that limited English proficient patients have full access to care, says Nakazawa. For example, an interpreter is needed during meetings with a nutritionist for lessons on how to prepare food for a restrictive diet or when patients are being trained on the use of medical equipment before they go home, she explains.
Currently the organization is trying to incorporate the use of interpreters into support groups. It has support groups for various types of cancer in which limited English speaking patients rarely participate even though they would benefit from them.
"We are trying to make people aware that they can participate. It is like any other type of encounter," says Nakazawa.
For more information on the use of interpreters to improve health literacy and patient safety, contact: