Nearly half of U.S. physicians say language and cultural barriers are at least minor obstacles to providing high-quality patient care, according to a study released by the Center for Studying Health System Change, a nonpartisan policy research organization located in Washington, DC.
The study highlights the need for healthcare providers to address non-English-speaking patients, especially as the percentage of non-English speakers rises.
The latest U.S. census data, collected in 2000, says 47 million residents over the age of five (18% of the total population) speak a language other than English at home. In 1990, 31.8 million residents (14%) reported they did not speak English at home, and in 1980, 23.1 million residents (11%) did the same.
Considering communication is at the heart of what staff members do, staff leaders should treat solving the problem of language and cultural barriers as a top priority.
Such obstacles "can lead to wrong clinical paths and poor outcomes, even disastrous outcomes," says Barbara Bogomolov, RN, MS, BSN, manager of refugee health and interpreter services at Barnes-Jewish Hospital, a member of BJC HealthCare, in St. Louis.
Use interpreters to bridge communication gaps
Patients rely on staff—such as nurses and case managers—to explain forms such as the Important Message from Medicare, provide instruction on performing post-discharge tasks, and ensure their concerns are met. However, many facilities lack resources to address non-English-speaking patients, says Bria Chakofsky-Lewy, RN, supervisor of Community House Calls/Interpreter Services at Harborview Medical Center in Seattle.
Harborview has used its Community Health Calls program to help bridge linguistic and cultural barriers for 16 years.
Originally established to serve the county's East African and Cambodian refugees, the program has since expanded to provide services to patients that speak Spanish, Vietnamese, and Somali.
Harborview employs 50 state-certified medical interpreters that speak 26 languages and serve a patient population that speaks 80 languages. Harborview had more than 100,000 interpreter encounters in 2009.
When Harborview has a patient that speaks a language that is not in its medical interpreters' repertoire, it gets help from an outside interpreter service agency. Facilities that do not have interpreters on staff should at the very least have access to a strong telephone interpreter service, says Bogomolov. Facilities should never rely on a patient's family members or a bilingual staff member in another department to provide interpretive services. "There are issues of bias, performance, patient safety, and confidentiality," she says.
The National Standards on Culturally and Linguistically Appropriate Services (CLAS) do not allow a patient's family members to interpret medical instructions unless the patient specifically requests that they be allowed to do so.
For more information on the CLAS standards, visit the U.S. Department of Health and Human Services' Web site at http://hcpro.com/url/1230.
Facilities can also take advantage of interpreters as a source of cultural information. "It's not all about language. We are used to Western-educated patients understanding their rights and obligations to make choices for themselves, but many [patients] come from cultures where that is not normal or appropriate," Bogomolov says.
Tip: Staff should have a pre-conference with interpreters before they interact with patients. During that time, interpreters will learn what the expectations are for the medical encounter, and they can alert healthcare providers of any cultural barriers that may obstruct those expectations.
Choose an interpreter
Interpreters should have credentials or some other means of displaying competence in both languages. Keep in mind good interpreters don't necessarily provide word-for-word translations. Sometimes medical terms have no direct translation.
"There is no word in Somali for MRI," Chakofsky-Lewy says.
Although they do not need to possess a strong clinical competence, interpreters should have enough familiarity with medical terminology to be able to create word pictures that the patient can understand.
To make sure that patients comprehend the information, it is best to ask them to explain what they have been told in their own words, Chakofsky-Lewy says.
Document encounters with non-English speakers
The Joint Commission (formerly JCAHO) is developing hospital accreditation standards that aim to advance effective communication and cultural competence.
The Joint Commission plans to release those standards this year for use in 2011. In the meantime, it has created a crosswalk between the CLAS standards and existing Joint Commission standards, which is available at http://hcpro.com/url/1229.
During its regular accreditation, The Joint Commission will review the medical record to evaluate a facility's ability to facilitate non-English speakers.
Facilities should develop a process to make sure that they properly document encounters with non-English speakers, Bogomolov says.
When patients are registered or admitted to Barnes- Jewish, they are asked what race and ethnicity they identify with and what language they prefer to use for communicating with healthcare providers.
Staff enter these data into patients' permanent records, so the questions are asked only once, and information flows down to the inpatient charts.
Based on the data, staff can determine whether interpretive services are required to bridge cultural or linguistic barriers.
"There should never be a situation where you cannot communicate with a patient," Bogomolov says.
This article was adapted from one that originally appeared in the April 2010 issue of Case Management Monthly, an HCPro publication.