Each year, Hispanic Heritage Month, which is celebrated from September 15 to October 15, represents a dedicated time to commemorate the history, culture, and contributions of Hispanic, Latino, and Latina Americans. For those in health care, it's also a time to reflect and discuss the health care challenges that disproportionately impact this community—one of which is inconsistent and inadequate interpreter services for limited English proficiency (LEP) patients.
Public health advocates citing federal legislation such as Title VI of the Civil Rights Act of 1964 have long called for language justice, recognizing that the health outcomes of many Hispanic, Latino, and Latina Americans are disproportionately impacted by language barriers–an experience that is broadly shared with other multilingual communities in the United States. More than 20% of the U.S. population speaks a language other than English at home and around 8% of the U.S. population is defined as LEP. Research shows that LEP patients are at higher risk for adverse medical events than English speaking patients.
I recently spoke with Joseph Gannett, a Louisiana State University Emergency Medicine resident at University Medical Center New Orleans. During the hospital's 2020 strategic planning process, Gannett proposed the hospital hire in-person interpreters to meet the needs of LEP patients who were not adequately served by the phone and audio/visual interpretation methods that were available. He explained that in many emergent and complex situations, language barriers prevent meaningful communication between clinicians and patients, which compromises quality of care, patients' trust in the health system, and staff morale.
Language justice as a health equity challenge
Today, many health care organizations exclusively rely on phone or audio/visual interpretation services, which are often insufficient and impede care-team workflow. Consequently, many clinicians and staff members try to "get by" with basic-to-intermediate language skills or rely on a patient's caregiver to act as the interpreter. But ad-hoc interpreters can be problematic because they are neither a neutral party nor trained in the interpretation process. Without the necessary training they may intentionally or unintentionally misrepresent critical information.
To illustrate these points, Gannett shared an all-too-common scenario:
Imagine you are a LEP patient. You arrive in the ED acutely ill. Health care workers bustle around you, putting in IVs, getting a chest X-ray, etc. The physician attempts to use the translator phone but the translator can’t hear you through the non-rebreather mask on your face, so they search for someone with Spanish-speaking ability in the department. A medical student, in broken, high-school level Spanish, determines a very basic story, but misses vital components of your past medical history, current medications, and symptoms leading to your 911 call.
In Gannett's experience, situations like this not only increase the potential for negative patient outcomes, but these scenarios undermine clinician morale. Consequently, Gannett argues for in-person interpretation combined with written translation of vital documents as foundational to provide quality, compassionate care for LEP patients.
Moreover, improved interpretation services also improve hospital outcomes and the organization's bottom line. A report published by the Agency for Healthcare Research and Quality (AHRQ) demonstrates that unaddressed language barriers increase the likelihood of medical errors that lead to physical harm, ineffective medication reconciliation, avoidable re-hospitalization, and prolonged length of stay for LEP patients. The report shows that costs associated with these quality metrics are compounded by ineffective translation services that delay informed consent and necessary medical procedures and may lead to increased malpractice claims. These potential costs clearly outweigh the investment in adequate interpretation services.
How health system leaders can bolster support for LEP patients today
Championing language justice is essential to provide safe, high-quality care for patients from diverse social, cultural, and linguistic backgrounds. Here are three actions leaders can take today to better support your LEP patients.
Understand your population's interpreter needs.
Some organizations might think they don't have enough LEP patients to warrant the additional investment, but the AHRQ report shows that the volume of LEP patients is often larger than most organizations think. Although many LEP patients may communicate reasonably well in English, they might still struggle to understand critical medical information or not be able to adequately raise important concerns or ask relevant questions. A suggested approach:
- Always ask patients their language preference. When a patient comes through your hospital's doors, a nurse or registration worker should consistently ask: "What's your preferred language?" If the response is anything other than English, follow up with: "Would you like an interpreter during your visit today?"
- Conduct community outreach, especially in high LEP communities, regarding how to maximize the effectiveness of LEP-related efforts. Work with community health workers and local health departments to clarify community needs.
Prioritize in-person interpreters for complex or emergent settings.
Phone or audio/visual interpreter services often only capture words and miss the subtle nuances of human communication such as eye contact and body language. Interpreters often become cultural brokers who meaningfully engage with the patient and their family in a way that audio and video cannot. And when used correctly, in-person interpreters quickly become a valued part of the care team. A suggested approach:
- Utilize in-person Spanish interpretation on a 24/7, 365-day basis to focus on high-risk situations.
- Develop a LEP policy that requires the use of certified medical interpreters in certain settings and train clinicians on proper interpreter utilization.
- Monitor usage of in-person Spanish interpreters and survey LEP patients with respect to their effectiveness.
- Track LEP patient outcomes and ensure their quality of care is equivalent to that of the English-speaking patient population.
Get staff engaged in language justice as part of patient safety and experience efforts.
In-person interpretation services are only valuable if they are effectively utilized. Best-in-class organizations engage staff in language justice by working with clinicians who champion this work and educating team members on the benefits of interpreters. Especially for LEP patients with complex medical issues, interpreters can be integrated into team meetings, huddles, briefings, handoffs, and discharges. A suggested approach:
- Organize a hospital-wide education effort on serving LEP patients.
- Schedule a town hall that includes community advocates and encourage collaboration and innovation to identify effective strategies.
- Track the number of fluent Spanish-speaking clinicians across service lines and develop recruitment pipelines that result in a workforce that reflects your patient population.
The disproportionate impact of Covid-19 on Hispanic, Latino, and Latina communities further reinforces the need for language justice as part of any organization's effort to ensure health equity for its patients. While Hispanic Heritage month is a timely opportunity to highlight the needs of LEP patients, language justice must be an ongoing, iterative effort working to ensure equal and compassionate care for all patients, regardless of background.
We would like to thank Dr. Gannett for being particularly generous with his time and insights.