People with limited English proficiency (LEP), those whose primary language is not English and have difficulty speaking and reading English, face an increased potential for medical errors without an appropriate interpreter to translate to and from the person’s primary language. Are family members, including children of patients, or medical staff members with varying degrees of fluency in the patient’s language adequate interpreters for LEP individuals or is the potential for error significant enough for health care providers to use professional interpreters?
“Ineffective communication between patients and providers can result in misdiagnosis, inappropriate treatment or medication errors. When a provider cannot communicate effectively about a disease or treatment, or when a patient cannot describe [his or her] illness, they lack the basic connection needed to result in appropriate care. Appropriate communication is necessary for ensuring quality and safety in health care,” Amy Wilson-Stronks said in a Department of Health and Human Services (HHS) and Joint Commission media release.
A study published on March 15, 2012, in Annals of Emergency Medicine, titled “Errors of Medical Interpretation and Their Potential Clinical Consequences: A Comparison of Professional vs. Ad Hoc vs. No Interpreters” found that “[p]rofessional interpreters who received more than 100 hours of training on average in medical interpreting had nearly two-thirds fewer errors than those with fewer than 100 hours of training and significantly fewer errors with medical consequences than ad hoc interpreters. Patient encounters that relied on ad hoc interpreters or no interpreters had significantly more errors, including some with potential clinical significance, such as mistaking tablespoons for teaspoons of medicine,” said lead study author Glenn Flores, MD, FAAP, of the University of Texas Southwestern Medical Center. The findings add to the growing body of evidence that paid, professional interpreters are essential for delivering high-quality health care to our patients, Flores added.
The study examined 57 encounters for pediatric patients whose primary language was Spanish, and English proficiency was limited. In 20 of the encounters, a professional, paid interpreter translated; in 27 of the encounters, an ad hoc interpreter, such as a family member, friend or hospital staff, provided interpretation; and in 10 of the encounters, no interpreters were involved. Researchers found that the proportion of errors with potential clinical consequences for (1) professional interpreters with 100 or more hours of training was 2 percent, (2) interpreters with less than 100 hours of training was 12 percent, (3) ad hoc interpreters was 22 percent, and (4) no interpreters was 20 percent.
Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race, color, or national origin in programs that receive federal funds. A failure to provide language access services for LEP persons may be a form of discrimination on the basis of national origin. Title VI and HHS regulations (see 45 C.F.R. §80.3(b)(2)) require recipients of federal financial assistance from HHS to take reasonable steps to provide meaningful access to LEP persons to programs and activities. Federal financial assistance includes grants, training, use of equipment, donations of surplus property, and other assistance. Recipients of HHS assistance may include hospitals, nursing homes, home health agencies, managed care organizations, universities and other entities with health or social service research programs, state Medicaid agencies, state, county, and local welfare agencies, programs for families, youth and children, Head Start programs, public and private contractors, subcontractors, vendors, and physicians and other providers.
The Guidance issued by the Office of Civil Rights (OCR) explains that the obligation to provide meaningful access is fact-dependent and starts with an individualized assessment that balances four factors: (1) the number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee; (2) the frequency with which LEP individuals come into contact with the program; (3) the nature and importance of the program, activity or service provided by the recipient to its beneficiaries; and (4) the resources available to the grantee/recipient and the costs of interpretation/translation services. There is no “one size fits all” solution for Title VI compliance with respect to LEP persons and what constitutes “reasonable steps” for large providers may not be reasonable for small providers, according to the Guidance.
For additional information supporting language access in health organizations see The Joint Commission and OCR video titled “Improving Patient-Provider Communication,” available at http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/index.html.