Partnering with Medical Interpreters Interpreter/Translation Training August 20, 2015 SF Public Library José Martín, LMFT, CHT Consultant/Lecturer/Professor National Board of Certification for Medical Interpreters, Testing Committee Member

Objectives Increase your understanding about the need for trained healthcare interpreters. Identify misconceptions about healthcare interpreting. Become aware of the best ways to partner with healthcare interpreters in providing services to LEP patients Become aware of regulations related to provision of healthcare interpreters

Why Use A Medical Interpreter? Improve quality of care Better health outcomes Legal ramifications (Title VI of the Civil Rights Act) Culturally and Linguistically Appropriate Services Standards Health care costs

Regulations mandating use of interpreters for LEP patients Federal Title VI of the Civil Rights Act of 1964 EMTALA-Emergency Medical Treatment & Labor Act Hill-Burton Act Executive Order 13166 CLAS Standards State Medicaid Regulations SB 853 Local Agency Requirements JCAHO DHS

The National CLAS Standards The National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care are intended to advance health equity, improve quality and help eliminate health care disparities by establishing a blueprint for health and health care organizations

CLAS Standards Standard 1 Health care organizations should ensure that patients/consumers receive from all staff member's effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. Standard 3 Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

CLAS Standards Standard 4 Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Standard 5 Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

CLAS Standards Standard 6 Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). Standard 7  Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

Role Expectations of Interpreters Treating the interpreter as a “robot” or voice machine. The only task of the interpreter is to pass the message verbatim from one person to the other. The interpreter is not expected to give any input, cultural or otherwise. This type of interpreter may work well in court settings, but may not be the most effective model for healthcare interviews. Treating the interpreter as a “provider”. The provider lacks confidence in working with the patient from a very different culture, and hands over the clinical judgment to the interpreter. Treating the interpreter as a “team partner”. The provider understands that he or she brings professional expertise and knowledge in the healing process. At the same time, the provider recognizes and respects the interpreter’s expertise in language, culture, and community resources. 9

Suggestions from Interpreters Make sure to greet the patient and the interpreter upon entering the room. Look directly at the patient, not the interpreter. Speak directly to the patient, not to the interpreter. Use first person voice—this will be how the interpreter is interpreting. Speak at the patient’s register—interpreters are not doctors and cannot translate high register medical information into layman language. 10

Suggestions from Interpreters continued Give the interpreter 25 seconds to introduce him/herself to the patient and to remind the patient of how to speak in a way that facilitates smooth, accurate and complete interpretation. Wait for your interpreter to finish transmitting your message before beginning to speak again. Interpreting protocol for healthcare encounters requires consecutive interpretation. Close your encounter with a patient by reviewing with the patient what tests, next steps, or prescriptions you are ordering. Know your language limits. 11

The Use of Family and Friends as Interpreters Results in omissions, substitutions, and errors in meaning that distort care Breaches confidentiality Creates barriers to the provider-patient relationship Upsets familial relationships and hierarchies that are deeply rooted in culture Is particularly problematic in the areas of gynecology, reproductive health, and sexually transmitted diseases Inhibits mental health treatment 12

Problems with Using Children as Interpreters Accurate and complete interpretation is difficult May lack awareness of the intent of the message Many common English words do not have language equivalents May not understand cultural terms used to describe illnesses Emotional Trauma for the child Role Reversal: Parents may resent having to rely on their children to handle adult situations 13

Trained vs. Untrained Interpreters Interpreter Skills: Mastery of Vocabulary, Grammar and Syntax in working languages Consecutive interpretation Simultaneous Interpretation Sight Translation Interpreter Ethics: Patient Confidentiality Impartiality Respect for Individuals and Their Communities Professionalism and Integrity Accuracy and Completeness Cultural Responsiveness Bilingual persons who speak two or more languages require training in order to transfer the message accurately and completely without interfering with the message. 14

Common Errors by Untrained Interpreters Not understanding the provider’s question or statement and failing to seek clarification Misinterpretation due to lack of adequate vocabulary to interpret culture-specific idioms,terms, and medical terminology, etc. Omissions 15

FACT Interpreters must: Be fluent in two languages Describe and explain terms that lie outside the language system of the patient Understand different world views Function as a cultural broker for patient and provider 16

Prior to Seeing the Patient Give background & set goals to “get on the same page”, before entering the room. Encourage clarification . Agree on pacing of the interpreting session. 17

Using Telephonic Interpreters Use a speaker phone; do not pass a handset back and forth. Remember that the interpreter is blind to visual cues. Let the interpreter know who you are, who else is in the room, and what sort of patient encounter it is. Let the interpreter introduce her/himself. 18

Positioning during session in person When employing a trained medical interpreter in person, it is best to place all three, i.e., provider, patient, interpreter in a triangle so that there is flow between provider and patient, patient and interpreter, and provider and interpreter. When accessing a Video/Voice interpreter, it is best to look at the patient and direct the communication at the patient, not the interpreter. 19

When using Video/Voice interpreting (HCIN) When accessing a HCIN interpreter, it is best to look at the patient and direct the communication at the patient, not the interpreter. Let the interpreter know who you are, who else is in the room, and what sort of patient encounter it is. Let the interpreter introduce her/himself. 20

Interpreter Protocol Speak directly to the patient, this means in 1st person with eye contact, as appropriate. Do NOT speak to the interpreter. Pause as necessary. Everything will be interpreted. No side conversations. Interpreters will interpret everything including rude remarks. 21

The Dialogue Keep a comfortable pace that will allow time for interpretation. Avoid medical jargon and idiomatic expressions to make the encounter less complicated. Listen before redirecting. Give full information on diagnosis, tests, and treatment. Confirm understanding and agreement with patient to ensure compliance. Encourage interpreter to clarify terms with you. Feel free to ask interpreter to interpret back to you whenever you are concerned about the accuracy and completeness of the interpretation. 22

Debriefing Use the interpreter as a resource for you regarding cultural nuances. Interpreters may NOT answer questions such as, “did you think Ms. Ruiz was sad, drunk, telling the truth, getting beaten by her husband, etc…today? 23

Ensure Accuracy and Confidentiality Do not ask the patients to bring their own interpreter. Do not ask another patient to help you interpret. Do not use children or family members. Do not use non-qualified hospital support staff. 24

Documentation Each interpreter will begin the session by saying, “Hello, my name is Yvette, Spanish interpreter cc103. How may I help you? You may need to identify on the chart that you used an interpreter and write down the name of the interpreter. 25

Ending Interpretation Session Close session with a review of next steps. Check with interpreter if there is something missing. Check with patient if he/she understands clearly what are the next steps. 26

Linguistic Issues Patients who are Limited English Proficient (LEP) may be unable to communicate effectively with their health care provider, seriously compromising quality of care Many LEP patients rely on family and friends to serve as interpreters. Using anyone other than a trained medical interpreter violates confidentiality, at risk of errors, may jeopardize patient safety, and affect quality of the interaction. 27

SUMMARY There are regulations mandating use of interpreters for LEP patients/clients This is a quality of care and safety issue Work with the healthcare interpreter to set pace of interaction with patient Treat the healthcare interpreter as a “team partner” There is a department policy on language services for LEP patients/clients Using anyone other than trained medical interpreter violates confidentiality, at risk of errors, may jeopardize patient safety, and affect quality of the interaction 28