Health Literacy Universal Precautions Toolkit, 3rd Edition

Patients who use a language other than English often do not get the health information and healthcare that others get. Addressing language differences is an essential health literacy strategy and critical for achieving health equity. It is also required by law. Practices participating in Medicare or Medicaid are required to provide language access for patients who do not speak or understand English very well, as well as the parents and guardians of patients who are under 18 or are incapacitated. The Americans with Disabilities Act, which covers people who are deaf or have hearing loss, has additional requirements. Failing to use acceptable forms of language access services can expose a practice to liability.

Actions

Assess language preferences.

• Ask all patients what language they want to speak and read in.
  • For example, you could ask, "What language do you want us to speak to you in?" and "What language do you prefer for written materials?"
  • Record patients' language preferences in the medical record.

  Why ask what language patients want to speak instead of how well they speak English?

  Everyone deserves to receive healthcare in the language they are most comfortable with.

  People who normally speak English very well may lose their ability when they are sick, tired, or frightened.

  People can be embarrassed to admit they have limited English proficiency.

  Let patients know about language access services.

  • List languages qualified bilingual clinicians speak in directories.
  • Display Interpretive Services Posters in your waiting and reception areas to make patients aware of the availability of free interpreter services.

  Use only acceptable language access services.

  • Provide language access services if patients or companions who are participating in the visit want to use a language other than English.
    • Consider all aspects of the practice that require language access services (e.g., appointment scheduling, signage, front desk, clinical visit, billing, followup communication, patient portals, secure messaging, obtaining patient feedback).
    • Bilingual clinicians and staff members whose proficiency in both English and the non-English language has been confirmed can communicate directly with patients in their preferred language.
    • Qualified healthcare interpreters. Many States have licensing and certification requirements, and qualifications and testing can vary. Qualified interpreters can include:
      • Staff who are trained as healthcare interpreters.
      • On-site dedicated healthcare interpreters.
      • Telephone or video healthcare interpreter services. Make sure you can access the necessary equipment (e.g., speaker or dual handset phones, video conferencing equipment) everywhere you speak with patients.

      Qualified Interpreters:

      Have demonstrated proficiency in speaking and understanding both English and at least one other language.

      Interpret effectively, accurately, and impartially while preserving the tone, sentiment, and emotional level of the original.

      Follow interpreter ethics principles, including client confidentiality.

      Never use unacceptable language access services.

      Unacceptable language access services include the following:

      • Clinicians or staff who are not sufficiently proficient in both languages. Do not try to “get by” with basic or intermediate language skills.
      • Clinicians or staff who are not trained and/or certified as healthcare interpreters. Research shows that people who not trained to be an interpreter make more clinically significant mistakes.
      • The patient's family and friends, unless they are qualified interpreters. Using family or friends makes it impossible to have a private conversation with your patient, as recommended in Include Family and Friends: Tool 22. Furthermore, family or friends may express their own views instead of the patient's view. If a patient insists that a family member serve as interpreter, you should respect that request, but also get a qualified interpreter to assure that information is accurately relayed.
      • Minor children should never be used as interpreters.

      Plan for language access in advance.

      • Use your patient assessment and community data to determine how best to meet language access needs (e.g., hiring bilingual staff, hiring professional interpreters, training staff as interpreters, contracting with a language agency, and telephone/video interpreter services).
      • When making appointments, check what language patients want to use. Make arrangements for language access services for patients that use languages other than English.
      • Decide how to handle unanticipated language access needs, such as using on-demand telephone interpreters.
      • Train staff how to:
        • Follow the practice's language access policies, including documenting interpreter use.
        • Match patients with qualified bilingual clinicians.
        • Schedule interpreters in advance for in-person and telehealth visits.
        • Access interpreters when unexpected needs arise.
        • Use health literacy strategies to communicate clearly. (Refer to Tool 4: Communicate Clearly).
        • Work effectively with interpreters.

        Provide written materials and videos in patients' languages.

        • Do not assume that non-English speakers, including sign language users, will understand notes or other materials written in English.
        • Decide what to translate, such as signs, forms, instructions, appointment reminders, and patient surveys.
        • Select qualified translators who use a high-quality process. You can find best practices in this Toolkit for Written Translation.
        • Consider options for multilingual patient portals.
        • Distribute multilingual health education materials, including videos in American Sign Language and other languages.
        • When you cannot obtain materials in patients' languages, enlist the help of interpreters trained in sight translation. Sight translation is reading a written document aloud in a different language from the one in which it is written.

        TIP

        Interpreters and translators are different professionals with different skill sets.

        Interpreters listen or watch in one language then speak or sign in another language.

        Translators read text in one language and write what it meant in another.

        Finance language access services.

        • Investigate whether insurers will pay for or have negotiated discounts with interpreters. Medicaid reimbursement is available in a number of States.
        • Consider:
          • Sharing language access services with local hospitals or among several practices.
          • Exploring language banks, which provide volunteers trained as healthcare interpreters.
          • Applying for grants to support interpreter and translation services.

          Track Your Progress

          Ask staff to record the number of patients they saw during a specified week who needed language access services and how these needs were met. Discuss instances when qualified interpreters or bilingual personnel were not used at the next Health Literacy Team meeting and brainstorm solutions. Repeat after 2, 6, and 12 months.

          Routinely conduct a review of medical records of patients with recent visits to ensure that language preferences are being assessed and recorded.

          Compile a list of the most common languages spoken by your patients. Compare that list with the languages used in the written materials you distribute. Repeat after 2, 6, and 12 months to see whether more non-English materials are available.

          Before implementing this tool and 2, 6, and 12 months later, collect patient feedback on a selection of questions about this tool from the Health Literacy Patient Feedback Questions.

          Additional Resources

          You can find resources for planning language access services, working with interpreters, and multilingual, easy-to-read materials in the appendix Language Access Resources (PDF, 207 KB).