A 4-year-old boy breaks his elbow and the trauma results in a blocked artery. The Spanish-speaking family sees an English-speaking orthopod who sets the fracture, but complications ensue, resulting in the removal of some of the arm's muscle tissue. An investigation determines that for all the surgical procedures, the surgeon provided an informed consent in English only and failed to use an interpreter. The case settles for $650,000.

A hospital radiology department finds a mass on a Spanish-speaking patient's left kidney, but the surgeon misreads the reports and proffers an informed consent in English for the right kidney instead. No interpreter is summoned, the patient loses both kidneys and ends up on dialysis for the rest of his life. The case settles for an undisclosed sum.

A 59-year-old Egyptian woman who speaks no English undergoes a urologic procedure. The surgeon removes her kidney, but blood loss leads to hemorrhagic shock, heart failure and death. An investigation determines that hospital employees had been unable to identify the patient's language, so they presented the Conditions of Admission in English without translation or a translator. The informed consent they presented, also in English, failed to mention the possibility of nephrectomy. The case settles for just under $100,000.¹

Every day, miscommunications occur between healthcare providers and patients who don't speak English well or at all. Many patients suffer and some even die as a result. Miscommunication is also expensive to facilities and providers. Patients with limited English proficiency (LEP) have longer lengths of stay than English-speaking patients, no matter their socioeconomic status.(2-4) They also have a significantly higher risk of 30-day readmission. When they encounter facilities that are not accommodating, they are likely to rate their satisfaction as low. And they may even sue. According to one study, 1 in 40 malpractice cases is directly related to poor or non-existent interpretation services.¹

The challenge of language barriers is of increasing concern. One in five U.S. residents speaks a language other than English at home and 40% of that group does not speak English well enough to effectively communicate with a healthcare provider.

As a percentage of American residents, non-English speakers have been on the rise for more than 30 years. One reason is that Congress loosened immigration laws in the 1960s. Globalization is another factor; people outside of the U.S. are more willing than ever to travel here for education and careers. Wars and civil conflict as well as the climate change that is occurring is Central America are also driving people out of their native countries and making them refugees. International law requires all countries to consider residency or citizenship for immigrants claiming refugee status.

Although the prevailing rhetoric right now doesn't indicate it, demand from the host countries also drives immigration. Every first-world country is dependent on immigrant labor. Immigrants take jobs native-born residents won't do. They're also important net contributors to health insurance. In fact, immigrants (most of them non-citizens) contribute a net surplus of more than $15 billion per year to Medicare. They pay in, but typically do not consume health services at the same rate natives do. The idea that immigrants are a drain on our healthcare financing system could not be more wrong; immigrants subsidize our healthcare system and deserve the best we have to offer.⁵

Finally, bridging language barriers is also our legal responsibility; U.S. law requires healthcare facilities to provide interpreter services to patients with LEP.6 Facilities must "take reasonable steps" like oral or written translation to provide LEP patients "meaningful access." The translation has to be free and high quality; facilities may not rely on unqualified staff to translate. Facilities must also post patients' rights in the 15 top languages of their states. With all that in mind, here are 9 tips for negotiating language barriers.

If a member of your staff is fluent in another language, consider designating him or her as an interpreter. There's no interpretation better than in-person interpretation. However, there are important caveats.

First, remember that health care is almost a language unto itself.7 ?Multilingual nurses or other staff trained in health care are almost always the best option. Relying on an untrained staffer like a housekeeper who speaks a dialect, but doesn't understand health care can be risky.

Second, if you're fortunate enough to have such a person on staff, strongly consider investing in training and certification before using them. Employees who function as interpreters should have a formal language skills assessment and understand medical terminology in the languages they speak.²⁷

It's not required, but I strongly recommend sending your employee to a course in medical interpretation. These typically require at least 40 hours of study and live demonstration of ability. It's possible to take a national exam to become board certified by either the National Board of Certification for Medical Interpreters ?or the Certification Commission for Healthcare Interpreters.

Even if you have the luxury of an interpreter on site, chances are you will need to choose a video or telephone service for languages not spoken by your interpreter. Choose carefully. The federal government does not require interpreters to be licensed or certified, but some states do and it's always a good idea. Although they may be nominally more expensive, trained interpreters can make a visit flow more smoothly and quickly, and save you money in the long run.

The research isn't conclusive on whether telephone or video interpretation is superior,8 but my anecdotal experience is that both patients and caregivers prefer video to phone interpretation.

A recent 208-patient survey at a children's hospital showed that Spanish-speaking parents supplied with video interpretation were almost 30% more likely to be able to name their child's diagnosis than were parents supplied with telephone interpretation only. Importantly, those same parents were 19% more likely to comply with post-encounter instructions than the telephone group.⁹

In a study at another pediatric hospital, Spanish-speaking moms actually rated video interpretation on an iPad more highly than certified Spanish-speaking physicians or certified Spanish-speaking interpreters.¹⁰

Video ?interpretation ?costs about $61 per patient, telephone interpretation costs about $31 per patient.9 How-ever, interpretation is reimbursable in many cases. Typically, facilities bill using HCPC code T-1013. ?If your state is not listed here, check with them; they may reimburse as well.^11-17

Smartphone translation apps can produce inaccurate results, especially when technical medical terms are involved. Most are designed to only translate basic sentences and not the specific language of health care. Mistakes may not matter much when you're ordering dinner in a foreign country, but in health care they can be fatal. Moreover, few if any of these programs are HIPAA compliant, so using these services to translate confidential patient information could expose your facility to very costly fines.

As you can see from the cases at the beginning of this article, documentation is critical. Record exactly when you used the interpreter, how the interpretation was done (in person, on video, by phone) and the interpreter's name. If you must rely on a staff member to interpret, document why you made that decision.

Create bilingual discharge instructions and patient education materials, using the languages most common in your area. Discharge instructions, in particular, should be in both English and the alternative language, because when patients are referred for home health services, home healthcare nurses who don't speak their language need to also be able to read the discharge instructions. The better your LEP patients understand their discharge instructions, the less likely they are to be readmitted or visit the emergency department.^21-22

We all know that post-op medications confuse even English-speaking patients. It's even harder for LEP patients.23-24 If possible, medication instructions should be in the patient's first language. Reviewing the medications with the help of an interpreter and then having patients teach back the instructions helps improve compliance and reduce complications related to medication errors.²⁶

If you have professional staff members who speak the language of your LEP patients, you have an excellent chance of improving patient outcomes and satisfaction. You can determine the demand for these nurses by looking at the census of your non-English-speaking patient population. Paying these employees a higher hourly rate is justified, because their language skills will reduce interpreter costs, improve outcomes, and reduce the risk of costly adverse events.²⁷

Remember that even bilingual patients can struggle with understanding and communicating about health issues. Something about being sick causes us to want to revert to our native language. I speak Spanish fluently, but when I was ill in Mexico, I longed to be able to tell my providers my problems in English. There's also evidence that as bilingual patients age, they become less fluent in their second language. And certainly, patients recovering from anesthesia may not be as sharp in their second language as they need to be.

We're still not anywhere near where we need to be with serving LEP patients. We need to rethink our approach to this challenge. Yes, everyone's busy, and it's disruptive to build in the extra time we need to effectively bridge communication gaps. But those facilities that succeed in doing so will not only satisfy their very clear moral and legal obligations. They will also improve their market share. Word gets around quickly in immigrant communities. If you speak the language, you will be rewarded with a huge influx of very loyal, deserving patients. OSM

Footnotes to this article can be found here.