Communication is key to quality health care. Patients communicate their symptoms and situations to clinicians, and those clinicians relay their findings and recommendations to patients. Effective patient communication can improve adherence to treatment, increase patient satisfaction and lead to better outcomes — which adds up to better overall health for the community.
But what about the growing number of patients and community members who do not speak English or who communicate in non-spoken languages, such as American Sign Language? One in five U.S. residents — more than 61 million people — speak a language other than English at home. Another million or so use American Sign Language (ASL) to communicate, making it the fourth-most-used language in the country. These individuals often need sign language interpreters — either in-person or through an ASL video interpretation provider — to receive proper care. Hospitals in all areas of the country are serving increasingly diverse populations, and as they work to improve the health of their communities, they must increasingly consider the diverse language needs and preferences of their patient populations.
To help meet the needs of the growing numbers of U.S. residents who communicate in languages other than English, Section 1557 of the Affordable Care Act mandates that hospitals provide qualified interpreters — using qualified staff or via phone and video — to help facilitate communication between clinicians and patients. Hospitals must also post notices of language service availability translated into the top 15 non-English languages in their state or area. Meeting the requirements of Section 1557 not only facilitates the delivery of quality, patient-centered care to people with limited English skills, but may also help hospitals identify needed services in the community, improve health promotion efforts in the community, and ultimately lower health care costs.
Effective Communication Increases Safety and Improves Outcome
The Agency for Healthcare Research and Quality (AHRQ) has set forth standards for effective communication: It must be complete (including all relevant information), clear (easily understood), brief (concise) and timely (within an appropriate timeframe). Communication is often challenging in the health care environment, but it can be even more difficult to meet these standards if the clinician and patient speak different languages.
Health outcomes for patients with low English proficiency (LEP) reflect this. Language barriers increase the risk for missed appointments, delayed care, preventable re-admissions, longer hospital stays and adverse events. In one study, children with disabilities had limited access to quality care when their parents did not speak English proficiently. Another study showed that patients who do not speak English well were more likely to experience an adverse event that resulted in moderate or severe harm. The researchers traced more than half of the incidents back to communication problems.
AHRQ has identified three common causes of errors in LEP patients and patients from diverse cultures — causes directly addressed by Section 1557. These include:
- Using family members, friends or other nonqualified people as interpreters: While it can seem like a convenient and logical solution to use family members as interpreters, it can open the way for errors if the person interpreting doesn’t understand medical terminology or doesn’t have full understanding of the patient’s language and culture. It also raises issues of confidentiality; patients may balk at disclosing sensitive information if a family member is interpreting.
- Clinicians who try to “get by” with basic language skills: While bilingual clinicians and clinicians from different ethnic groups bring important depth and understanding to patient care, especially for diverse populations, most still need interpreters or language services to ensure effective communication. Even if the provider is proficient in the patient’s language, communicating in one language to the patient and another to other staff puts extra burden on the provider. It also makes it more difficult for team members to detect potential errors or patient safety concerns.
- Insufficient knowledge of cultural beliefs and traditions that affect care delivery: Patients who don’t speak English proficiently may also have cultural beliefs and traditions that affect how they understand the medical encounter. Truly patient-centered care requires not only an understanding of the patient’s language, but also sensitivity to their culture.
According to AHRQ, errors are most likely to occur during “high-risk situations,” such as medication reconciliation, patient discharge, informed consent, emergency visits or surgical care.
Improving Population Health Through Language Services
By identifying and addressing language barriers in their patient populations, hospitals can improve health outcomes while reducing health disparities, reducing readmissions and increasing patient safety. This, in turn, helps improve the health of their community. Here are some steps hospitals can take to address their communities’ language needs.
- Collect data on language needs: Knowing the community is the first step in meeting its needs. Collecting demographic information on patients who seek services as well as looking at the characteristics of the population as a whole (including those who do not currently seek services) helps hospitals design services that promote population health. Language data plays an important role in this process. In addition to asking patients about language preference, hospitals should include languages spoken in the area on community needs assessments and strategic planning efforts. A language services provider can assist by setting hospitals up to track their utilization of interpreter services by language, measuring demand.
- Build on community relationships: Many hospitals already have strong relationships with community-based organizations. Building on this tradition, hospitals can reach out to faith organizations and other formal and informal community groups that serve ethnic minorities to increase their outreach to these communities. Including representatives from these groups on community advisory boards or in other hospital activities can help bring these populations in for hospital services.
- Develop language services to meet community needs: Each hospital and community is different, so each must design and develop language services for their own unique situation. The increasing number of languages spoken in both urban and rural areas calls for a multipronged solution.
Requests for language services have increased steadily at Boston Medical Center (BMC) during the past 16 years. In 2016, the hospital had requests for more than 215 languages. Spanish was by far the most requested language, but others include Somali, Albanian, Vietnamese, Tigrinya and Cape Verdian. Recognizing that interpretation staff can’t cover all of those languages, BMC has employed a combination of BMC’s on-site, face-to-face interpreters with phone or video interpretation provided through its partnership with CyraCom, whose Interpretation & Translation Services have earned the exclusive endorsement of the American Hospital Association. The hospital also offers free training to providers to ensure that their language skills are adequate before they can interpret for patients.
In Florida, Lee Health provides care to Lee County, a community of 650,000 where one in four residents speaks a language other than English at home, and Spanish, Haitian Creole, German, and ASL are all in demand. The county also deals with socioeconomic struggles, and the illiteracy rate is 13 percent. Successful strategies for overcoming these obstacles include a community outreach program which established Lee Community Health Centers in disadvantaged neighborhoods, equipped with CyraCom video carts for video and ASL interpretation.
With effective language services, hospitals can communicate effectively with patients from diverse backgrounds and reach further into their communities with needed services and health promotion activities to meet their population health goals.