CLINICAL PRACTICE PROVIDING CARE Approved: Department Director, Senior Leader Policy Policy & Procedure Standardized Procedure Title: Formerly: Interpreting Services: Foreign Language, Limited English Proficiency and Hearing Impaired Issued: 3/1992 Revised: 12/2012, 12/2010 Reviewed: 4/2011 INTERPRETER: LANGUAGE ACCESS FOR LIMITED ENGLISH PROFICIENT (LEP) AND HEARING IMPAIRED PATIENTS AND SURROGATE DECISION-MAKERS PURPOSE: Southwest Healthcare System (SWHS) understands the importance of effective communication between patients and their providers of care, treatment and services. Effective patient-provider communication is a patient right and necessary for patient safety. The purpose of this policy is to ensure the provision of quality patient care to all Limited English Proficient (LEP) hearing impaired patients and surrogate decision-makers and to provide a mechanism whereby they are able to understand their medical conditions and treatment options. POLICY: A. SWHS respects the patient s right to receive information in a manner he/she understands. B. LEP and hearing impaired patients of SWHS and/or their surrogate decision-makers, shall have services provided to them in their primary language or have interpreter services provided to them during the delivery of all significant healthcare services. C. Patients of SWHS and/or their surrogate decision-makers are informed and supported to participate in their treatment and plan of care. The basis for determining whether a barrier to communication exists is based upon the patient s/family statement of need and/or the assessment of the healthcare provider. D. In assessing whether a barrier exists, SWHS shall identify the patient s oral and written communication needs, including the patient s preferred language for discussing health care. E. New employees of SWHS will be trained on this policy and the acquisition of interpreter services during their new hire orientation. Training on this policy and procedure for current SWHS staff will be incorporated into other ongoing trainings. F. The translation of written documentation into a language other than English will occur through the contracted language services provider. Translations from web sites or other institutions will not be adopted by SWHS use without going through the contracted language 3-12.doc Page 1 of 7
services provider for translation. G. Southwest Healthcare System will inform the LEP and/or hearing impaired patients that the availability of a qualified medical interpreter and/or language assistance is legally guaranteed, free of charge and available within a reasonable time frame. H. If the staff or the physician speaks the same language as the patient, no interpreter is necessary for social conversations or to convey or receive simple messages, basic questions and/or general instructions (i.e., instructing patient that you wish to bathe them, telling them the medicine is for treating their pain, etc.). Any interpretation that requires asking or giving of detailed medical information and/or informed consent requires the use of a qualified medical interpreter available through the contracted language services provider. I. Language Line Services should be used for all medical communication needs. Family members are discouraged from interpreting information other than basic conversational information. J. Should patients/surrogate decision-makers insist upon the use of a friend or family member to provide them with interpretation, SWHS personnel shall additionally retain a qualified medical interpreter to participate in the exchange to ensure that it represents an accurate portrayal of the information to hospital staff and patients. K. If there is a question as to which language the patient speaks, the Please Point poster will be used to identify the LEP patient s spoken language. The Please Point poster is available on the patient care units and on Sharepoint under the Resources tab. L. Minor children and other patients will not be used to interpret information. M. SWHS provides access for LEP patients and their surrogate decision-makers in all clinical and support areas and this service is available during all hours of operation at no cost to the patient and/or family. N. Communication disorders and variations that are recognized by the American Speech, Language and Hearing Association (ASHA) are addressed within the scope of care of a Speech-Language Pathologist. Refer to policy for further clarification. DEFINITION: A. Limited English Proficient (LEP): A limited ability or inability to speak, read, write or understand the English language at a level that permits the person to interact effectively with health care providers. B. Interpretation by Telephone: A form of remote interpreting that offers the delivery of interpreter services through telephone technology. The interpreter is at a different physical location than the patient. Telephone interpreting allows for an audio connection between the patient, physician or other caregiver and interpreter. C. Video Remote Interpreting (VRI): A form of remote interpreting that offers the delivery of an interpreter services for the hearing impaired population through video technology. The interpreter is at a different physical location than the patient. Video interpreting allows for a visual connection between the hearing-impaired patient, physician or other caregiver, and interpreter. D. Financial Number (FIN): A number assigned to patient that is specific to one encounter to the hospital. 3-12.doc Page 2 of 7
PROCEDURE FOR USING INTERPRETATION BY TELEPHONE: A. Dual Handset Device: 1. Take the assigned dual handset or dual cordless phone into the LEP patient s room or patient care area. 2. Unplug the existing phone line and plug the line into the dual handset phone jack. 3. To make a call, pick up the left handset. If you pick up the right handset first, you will not hear a dial tone. 4. Press the top button labeled Interpretalk. 5. When prompted for your access code, press the button labeled Access Code. 6. An LSA Call Center Coordinator will pick up the line and request the following information: a. Your name b. Your department c. The patient s FIN number d. The language that your patient speaks. 7. The Coordinator will then connect the Interpreter to the line and provide the Interpreter s ID Number. 8. The Interpreter s ID Number will be recorded in the patient s medical record to validate that a medically qualified interpreter was provided. Once the Interpreter is connected, pick up the right handset and hand it to the LEP patient. All parties are now on the line and the conversation may begin. When the interpreter joins the call, brief the interpreter about the call. B. Cordless Phone Device: 1. Take the assigned cordless phones into the LEP patient s room or patient care area. Leave the cordless charging base in it s designated location. 2. You will be asked to give your language request, your client ID number (201195), the organization s name (Inland Valley, Rancho Springs) and your personal code (caller s last name) to Language Line Services attendant. 3. When the interpreter joins the call, brief the interpreter about the call and hand the phone to the person you are dealing with. 4. The phone can then be handed back and forth to non-english speaker and the person instigating the call. Under your direction, the interpreter will relay your messages until your communication needs are complete. 5. Continue until the call is completed. To end the call, state End of Call. 6. For convenience, 2-hand-held receiver telephones can be used for outbound calls. All three people (patient, healthcare provider and interpreter) can be on the telephone conversation at the same time. C. Splitter Devices: 1. A splitter is in place in areas that require the addition of an extra handset to any telephone 2. To use the splitter, unplug the handset cord from the telephone base and plug the splitter into that port. 3. Plug handset cord into the splitter. 4. Plug additional handset into the splitter. This handset is for the patient/family member. 5. Dial the toll-free number (877) 274-9745 and enter access code: 4502523. 6. Follow the instructions provided by the coordinator. 7. Record the interpreter ID number in the patient s medical record and hand the extra 3-12.doc Page 3 of 7
telephone to the patient/family member. D. Video Remote Interpreting (VRI) for the Hearing Impaired 1. Click the icon on the desktop of the laptop provided for this purpose. You may acquire this laptop by checking it out from the House Supervisor. 2. Log-in with your username and password. 3. Click on the Video Remote Interpreting link. 4. Complete the information requested in the fields on the pop-up screen and click NEXT. 5. The main VRI window will appear which indicates that you are connected to the interpreter. 6. Once the video session is complete, end your session by clicking the disconnect button (looks like a seat belt). Do not click the x in the top right corner as this does not terminate the session. 7. Once the session has ended, details of the interpretation are automatically displayed. You may use this information when documenting in the patient s medical record. E. Documentation: 1. What was conveyed to the interpreter and a general overview of discussion topics and decisions made. 2. Interpreter ID/Code # 3. Date, time and signature of communicator 4. Complete an evaluation of the service you received by visiting the Language Services Associates website. The link can be found under Helpful Web Links under the Resources tab on SharePoint. Related Policies: Definitions of Communication Disorders and Variations Commly Treated in Speech: Language Pathology. References: 1. The Joint Commission on Accreditation of Healthcare Organizations Standards 2012 2. Advancing Effective Communication, Cultural Compentence and Patient and Family Centered Care: A Roadmap for Hospitals. The Joint Commission, 2010. 3. Title VI of the 1964 U.S. Civil Rights Act, 42 U.S.C., 2000d. 4. Office of Civil Rights, U.S. Department of Health and Human Services, Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons, 68 Fed. Reg. 47311 (August 8, 2003). 5. California Government Code 11135 and 7290 et seq. 6. California Health and Safety Code 1259. 7. Office of Minority Health, U.S. Department of Health and Human Services, National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care, 65 Fed. Reg 80865 (Dec. 22, 2000). Attachments: 1. Desktop Reference card. 2. Please Point Reference document. REFERENCES: A. www.lep.gov 3-12.doc Page 4 of 7
B. Best Practice Recommendations for Hospital Based Interpreter Services, Commonwealth of Massachusetts, Massachusetts Department of Public Health C. The Joint Commission, HR.01.02.01 (2012) 3-12.doc Page 5 of 7
Attachment 1: Desktop Reference Card 3-12.doc Page 6 of 7
Attachment 2: Please Point Reference document 3-12.doc Page 7 of 7