Limited English proficient

I. Problem/Challenge.

People who primarily use a language other than English and have a limited ability to speak, read, write, or understand English can be described as limited English proficient (LEP). This may include people who are deaf or hard of hearing.

Hospitals that receive federal funding are required to provide LEP individuals with meaningful and non-discriminatory access to their services in order to comply with Title VI of the Civil Rights Act. In addition, being LEP is a risk factor for worse inpatient health outcomes, longer hospital stays, and higher readmission rates. In the hospital setting, LEP patients’ care may be adversely affected by ineffective communication at critical points (e.g., admission, discharge, end-of life care, and other interactions leading to health-related decisions).

Interpreters can render information from one language into one or more other languages. Professional, trained interpreters produce fewer clinically significant errors than ad hoc interpreters (e.g., untrained hospital staff, patient’s family or friends). The use of professional interpreters for these LEP patients can reduce health disparities and lead to improved health outcomes.

The following describes what should be done by the hospitalist when working with an LEP patient.

II. Identify the goal behavior.

1) Identify the patient as LEP and in need of an interpreter.

2) Identify a care provider who is known to be fluent in the patient’s primary language who can work consistently with the patient.

3) If one is not appropriately available, obtain a professional interpreter at the bedside for clinically meaningful interactions.

III. Describe a step-by-step approach/method to this problem.

1) Note a communication breakdown or discordance when talking to a patient in English. For example:

The patient’s English usage, such as grammar, appears unusual: “When I drink my medications…”
The patient seems not to understand your statements or questions despite attempts to communicate clearly.
You suspect for any reason the patient is not fluent in English.

2) Identify the patient’s primary language. A practical approach follows:

Ask, “How well do you speak English?” Standardized responses are “not at all, not well, well, or very well.”
If “very well,” language assistance is probably not needed but can be offered.
If “not at all” or “not well,” obtain an interpreter as below.
If “well,” ask, “In general, in what language do you prefer to receive your medical care?” Responses should be “English, [other language], or both English and [other language] equally.” If the patient chooses [other language alone], then proceed as below.

3) Obtain a professional interpreter per facility protocol. This may require contacting a language services coordinator, perhaps in Patient Relations or an interpreting services department. Staff may help with obtaining these referrals (e.g., clerks, nurses, house supervisors, patient care coordinators).

4) If a professional interpreter is not available, obtain professional telephone/video interpretation. Your hospital may have access to interpretation vendors. This may require assistance from staff as above.

Telephone and video interpretation may differ from in-person interpretation or each other in quality. LEP people using video interpretation, as compared to over-the-phone, may better recall diagnoses, and patients have expressed preference for the video approach.
LEP people with severe illness (e.g., stroke or severe sepsis) or complex psychosocial circumstances (e.g., breaking bad news) may better tolerate video interpretation when in-person interpretation is not available.

5) If no professional interpretation services are available and clinical urgency demands prompt interpretation, seek a hospital employee (preferably a care provider such as a physician or nurse) who speaks the patient’s primary language. It is preferable to work with a bilingual employee who has received training in medical interpretation. If one has not received such training, this is considered an ad hoc (untrained) interpreter.

Assess the person’s fluency. Ask if s/he is comfortable discussing medical terminology and concepts in the patient’s language.
If s/he is not comfortable doing so, find someone who is.

6) If no one else is available, or if the patient insists, request the help of a family member or friend. Do not ask a minor for assistance.

7) Before beginning the patient interview, prepare your consultant just as you would any consulting specialist. Explain to the interpreter what will be asked or discussed with the patient. Ask if the interpreter has any questions before beginning.

8) Address the patient directly, using first-person statements; avoid addressing the interpreter. When working with spoken language interpreters, some patients may prefer to position the interpreter next to or slightly behind the patient. Present each question or statement as a single conceptual unit. Avoid asking multiple questions or presenting multiple concepts at once. After each question or statement, allow the interpreter time to interpret your statement AND to interpret the patient’s response. Avoid medical jargon, acronyms, or idioms when possible.

9) Close the communication loop (teach back) by eliciting the patient’s understanding. For example:

“Tell me what you understand about what I have explained.”
“It is my understanding that you have been having [symptom] for [period of time]. Is that correct?”

10) You may need to repeat questions in multiple ways to confirm patient understanding. (“Are you having chest pain?” “Tell me about your chest pain.”)

11) At the end of the discussion, ask if the patient has any questions. Then ask the interpreter the same.

12) Document interpreter involvement in the medical record. Communicate the patient’s need for language assistance to other care providers involved.

IV. Common Pitfalls.

When uncertain if a discussion warrants an interpreter, err on the side of providing language services.

Allow for additional time for interactions with patients who may require an interpreter.

Patient pitfalls

Err on the side of language assistance. Avoid assuming that, because the patient uses some English, s/he can understand you or express concepts adequately in English.

In the case of deaf or hard of hearing patients, writing in English cannot be assumed to be an adequate substitute for an interpreter.

If the patient appears not to follow the conversation, consider whether this may be due to interpretation clarity or a problem on the patient’s part.

If a hospital document is being used, seek a professionally translated version (e.g., informed consent form).

If the patient is English proficient but an involved family member is LEP, language services can be provided for the family member as well.

Professional interpreter pitfalls

Fluency does not mean interpretation; simply knowing both English and another language does not qualify a person to be an interpreter.

Ask about the interpreter’s qualifications. Do not assume the interpreter is certified or qualified.

Many regions do not yet provide certification for local interpreters. Inquiring about medical training or experience will be helpful.
Many spoken language certifications are available for medical interpreters, although no one is the single gold standard.
For signed language interpreters, national certifications (and some state-level) are required for general interpreting practice, although these act as a minimum standard. No medical interpreter certifications are currently available for signed languages.
Ask if certification is current. Certification systems undergo multiple revisions over the years and some old forms may no longer be valid.

Ad Hoc interpreter pitfalls

Never use a minor as an interpreter.

Untrained (ad hoc) interpreters should not be used. If situational urgency demands otherwise, gauge the person’s familiarity and comfort with both the language and the healthcare concepts, along with ethical issues such as patient confidentiality. This is best done before the patient discussion than in retrospect.

Consider whether the ad hoc interpreter has a vested interest (emotional or otherwise) in the patient’s health outcome or decisions.

V. National Standards, Core Indicators and Quality Measures.

The Joint Commission standards relevant to language services include but are not limited to:

Identification of and documentation in the medical record of the patient’s preferred language and communication needs.
Provision of information in a form that takes into account the patient’s language and ability to understand.
Provision of interpreting and translating services, which may include hospital-employed interpreters, contractors, or trained bilingual staff, and can be provided in-person or by telephone or video.
Definition by the hospital of staff qualifications specific to job responsibilities, which includes interpreters. “Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964.” (HR.01.02.01, EP1, Note 4)

The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL: The Joint Commission, 2010.

Other standards and guides can be found within the Department of Health and Human Services, Executive Summary. September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/lepguide/lepguidesumm.html.

VI. What's the evidence?

Karliner, LS, Napoles-Springer, AM, Schillinger, D, Bibbins-Domingo, K, Perez-Stable, EJ.. “Identification of Limited-English Proficient Patients in Clinical Care”. J Gen Intern Med.. vol. 23. 2008 Oct.

Juckett, G, Unger, K.. “Appropriate use of medical interpreters”. Am Family Physician. vol. 90. 2014 Oct 1. pp. 476-80.

Silva, MD, Genoff, M, Zaballa, A, Jewell, S, Stabler, S, Gany, FM, Diamond, LC.. “Interpreting at the End of Life: A Systematic Review of the Impact of Interpreters on the Delivery of Palliative Care Services to Cancer Patients with Limited English Proficiency”. J Pain Symptom Manage.. 2015 Nov 5.

Lindholm, M, Hargraves, JL, Ferguson, WJ, Reed, G.. “Professional language interpretation and inpatient length of stay and readmission rates”. J Gen Intern Med. vol. 27. 2012 Oct. pp. 1294-9.

Locatis, C. “Comparing In-Person, Video, and Telephonic Medical Interpretation”. Comparing In-Person, Video, and Telephonic Medical Interpretation. vol. 25. 2010. pp. 345-350.

Casey, K. “Effect of Telephone vs Video Interpretation on Parent Comprehension, Communication, and Utilization in the Pediatric Emergency Department: A Randomized Clinical Trial”. Effect of Telephone vs Video Interpretation on Parent Comprehension, Communication, and Utilization in the Pediatric Emergency Department: A Randomized Clinical Trial.. 2015. pp. 1-9.

Price, EL. “Interpreter perspectives of in-person, telephonic, and videoconferencing medical interpretation in clinical encounters”. Interpreter perspectives of in-person, telephonic, and videoconferencing medical interpretation in clinical encounters. vol. 87. 2012. pp. 226-232.

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