September The Medical Interpreter Project is funded primarily by a grant from the global organization Ronald McDonald House Charities, Inc.

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1 September 2007 Dear Friend, As we begin a second phase of our partnership with Ronald McDonald House Charities and children s hospitals across the country, we want to share what has been accomplished in Phase 1 and how much more we hope to achieve in Phase 2. Barbara Rayes, Master Trainer Juanita Francis, Manager Erin Rodda-Kuroiwa, Coordinator My analysis shows the cost of training 20 bilingual employees in the SBA class and elevating their interpreter skills is similar to the budget necessary to recruit and hire three full time interpreters. Edgardo García, Children s Medical Center Dallas The Medical Interpreter Project is funded primarily by a grant from the global organization Ronald McDonald House Charities, Inc. As the United States becomes increasingly diverse, effective communication becomes a most critical healthcare quality issue. Hospitals face an enormous challenge in providing quality health services to limited English speaking patients and their families. The national Medical Interpreter Project (MIP) is helping deliver better, more accessible, and safer health care to children and families by increasing the availability of trained, culturally competent Spanish-language medical interpreters. The Project offers: The 60-hour Spanish Bilingual Assistant (SBA) course curriculum, materials, and testing tools A Phoenix-based train-the-trainer program for instructor candidates from partner hospitals One year of mentoring instructors as they work within their organizations to implement the course and train bilingual employees and medical interpreters A Virtual Learning Community for partner hospital instructors, supervisors, and administrators to share best practices The original two-year Project goal was to train 20 instructors who would establish classes in their respective hospitals training at least 400 employees in the SBA course. The capacity building expectation is that the trained instructors continue to teach more interpreters and bilingual employees in the coming years. We are proud to report that 24 of 25 trained instructors are actively working and teaching in 20 metropolitan regions. Eighteen instructors (75%) taught more than 574 students in 24 SBA courses. A total of 470 students (82%) successfully completed the course. Survey data from partner hospitals indicate that this Project impacts an average of 18,750 emergency room visits and 80,000 outpatient visits per hospital per year. Thank you to Ronald McDonald House Charities, Inc. for two more years of funding and to each instructor, supervisor, administrator, and language expert who helped inform this Project. These are shared successes and we are grateful to each of you. Juanita Francis, RN, MBA Project Manager, MIP Phase 1

2 Project Accomplishments Built organizational support at partner institutions in concert with trainers, supervisors, and administrators Mentored instructors via a Virtual Learning Community with master trainer and other national experts Developed and maintained the Language Services Supervisor Learning Community with virtual roundtable discussions on a bimonthly basis facilitating a national dialogue regarding cost-effective implementation of language services in children s hospitals Internally and externally validated course objectives, testing tools, surveys with hospital interpreter focus groups and national experts Further refined and validated a comprehensive set of screening tools and pre- and post tests Beta tested three new instructional units on Medical Interpreting for Children, Medical Interpreting for Families, and Extreme Interpreting Gathered and aggregated data on the Confidence Scale for Interpreters Updated references and resources Surveyed instructors and administrators to evaluate Project impact Lessons Learned Leadership is critical. Hospitals with CEO and physician champions who prioritized diversity and access issues implemented faster, taught the most classes, and performed best on quality measures. Successful implementation requires a strong working partnership between the instructor and supervisor as well as a written agreement with the Project. Workforce development is an additional benefit of offering the classes. Many SBA students are continuing their educations, with some entering nursing or medical school. Partner hospitals spend between 0.03% and 2.0% of annual operating expenses on language services and employ from 2-26 full time interpreters, with an average of 12 staff interpreters per hospital. Hospitals from different regions are successfully meeting their language services need in a variety of creative ways volunteers who have lived in other countries, employed interpreters, contract interpreters, and bilingual staff interpreters (dual role). Consistent data collection processes and measures are needed for quality improvement purposes and sharing of best practices between partner hospitals. There was inconsistency in how partners determined whether an interpreter was needed and how they tracked interpreter encounters. The Joint Commission implemented a new accreditation standard in January 2006 requiring the patient s language and communication needs to be entered in the patient record. Interpreter trainers need practical support. Instructors benefit from practical support, not only discussing classroom management, but also connecting with experts and with peer instructors, having a supply of teaching materials, and practicing in front of peers before teaching. Learning needs of heritage speakers are different from learning needs of students who acquired English or Spanish after childhood. Students who grew up being bilingual, or heritage speakers, make up 70% of the students and many benefit from a focus on culture and formal voice. Students who learned Spanish later tend to benefit from a focus on Spanish grammar and vocabulary. Students who learned English later tend to benefit from pronunciation exercises and a focus on English vocabulary. All students benefit from practicing together and exploring each other s experiences in authoritarian vs. learner-driven class environments. Measuring student confidence (self-efficacy) is new for interpreter trainers and offers specific information that makes the training more effective. MIP developed and pioneered a Confidence Scale for Interpreters based on seven years of research and expert review of core competencies for medical interpreters. Measuring confidence and comparing the results with tests of knowledge offers a unique view of the needs and progress of students in interpreter training programs. To fix something, we must first understand.

3 Why This Project What s the Evidence? Limited English proficiency is associated with a number of poor outcomes in children including lower utilization of ambulatory services, lack of primary health care and poor health (Kirkman-Liff, et al, 1991). For limited English proficient children and their families, studies document that medical interpreters frequently are not used; there is a lack of trained interpreters; more access barriers exist; and those who need but do not get interpreters do not accurately understand their diagnosis and treatment (Flores, et al, 2003). Spanish-speaking patients whose families have a language barrier seem to have a significantly increased risk for serious medical events during pediatric hospitalization compared with patients whose families do not have a language barrier (Cohen, et al, 2005). In one tragic example, an 18-year-old Spanishspeaking patient said he felt intoxicado before collapsing. A paramedic mistook the word and the patient spent over 36 hours being worked up for a drug overdose, delaying treatment of a ruptured brain aneurysm and resulting in quadriplegia. The case was settled for $71 million (Ku and Flores, 2005). Interpreting for Children The national standards of practice were developed with adults in mind. In a children s hospital, most of the time, the interpreter is repeating messages spoken by adults. But interpreting for children also is a daily activity, and there is a need for ongoing national discussion about interpreting for children. In terms of practice, these are our observations of English/Spanish interpreters who work with children in hospitals, based on focus groups held with forty children s hospital interpreters. Best practices when interpreting for children needs to continue to be explored in ongoing national dialogue that includes many language groups, experts, and the children themselves. Position and Gaze: Standing close to the child (but not between the child and parents) and getting physically on the level of the child by sitting, squatting, or kneeling, to make deliberate eye contact, are common techniques for helping the child trust and understand the interpreter. Consecutive Mode and Third Person Speech: Listening to two people talk at once can be confusing for a child. If the child has neurological or psychiatric difficulties, for example, with sensory integration, learning, or coping with frustration, hearing two people speak at once can provoke agitation. Transferring the speech of a person saying I to another person is an abstraction most children have not developed the ability to understand. Using the consecutive mode almost exclusively, as well as the third person, are common practices among interpreters who work with children, at least up until high school, and beyond for those with significant developmental delays. Ongoing Work Train and mentor 30 additional instructors from children s hospitals around the country in Spanish-language medical interpretation (15 each year) funded by RMHC, Inc. and train and mentor an additional instructors from general hospitals Produce the 4th edition of Spanish Bilingual Assistant: Introduction to Medical Interpreting, and include more scripts for interpreter practice Provide technical assistance to and share best practice information with partnering health care organizations via a Virtual Learning Community Consider creative ways to replicate the Spanish Bilingual Assistant course model for other language communities Talking Directly with the Child: Taking a moment to get to know the child and explain the role of the interpreter is consistent with standards for working with adults. What is different for children s hospital interpreters is the amount of direct communication with children, for example, singing songs or telling stories in a child s own language as a measure of comfort during medical procedures.

4 What do students learn in SBA? Spanish Bilingual Assistant is designed for bilingual health care staff and interpreters. The 60-hour course is taught in 3 domains, Language, Culture and Practice. Language increase medical vocabulary in both languages in the context of reviewing anatomy, physiology, pathophysiology; organize personal word bank Culture develop awareness of cultures associated with English and Spanish languages and strategies for helping people of different cultures work together Practice improve skills in problem solving, memory, register, position, working within scope of practice Bilingual Service Interpretation has long served two distinct purposes. One is to facilitate communication, such as when two people want to talk with each other but don t speak the same language, so a third party interprets for them. The other purpose of interpretation is to learn and to improve language skills. Bilingual health care workers enroll in SBA and use the interpretation exercises to improve language skills so they can do their jobs better in two languages. Medical Interpreting A major task of interpreting is repeating in the other language everything that was said, the way it was said. SBA provides an opportunity for interpreters to explore the foundations of this task in terms of vocabulary, culture, and skill. What is the impact of SBA? Liliana s mother takes her to the neurologist. The child has moments when she turns her head, moves her lips, and does not respond to her mother. The doctor asks what happens right before and after the episodes, if she s ever had an MRI, and if she s ever been diagnosed with seizures. In this scenario, there are at least six words that are challenging to interpret but critical to understanding. SBA students complete a 100-item, fixed-response test booklet used as a pre- and post test. Preparation of the booklet has taken years and included input from academicians, experts, and practitioners. The test booklet is divided into three sections: a confidence scale, an evaluation of knowledge, and a demographic questionnaire. From August 16, 2006 to May 31, 2007, we studied 238 SBA students. Students consistently rated their confidence lower on several tasks, among them, interpreting technical vocabulary. Pre-test confidence in the Language category was 67%, and pre-test knowledge in the most difficult Technical Vocabulary, Level 3, was only 35%, far below a passing grade. By using two different types of assessment, the confidence scale and a traditional test, students have the opportunity to show the instructor what they need to learn and what they are capable of accomplishing. Confidence in language skills improved by 13%, and command of the most difficult and risk-prone technical vocabulary increased by 34%. Finally, confidence in the Assertiveness category increased by 13%. Items in this category include tasks related to working within one s scope of practice even when a provider requests more. Accuracy, knowledge, and assertiveness work together to make communication safer. The most significant gain impacts children like Liliana and her family. Because the SBA-trained interpreter has a 34% improvement in Level 3 technical vocabulary, she accurately interprets seizure and does not call it a heart attack or stroke in Spanish. Liliana s mother is able to give truly informed consent because the interpreter knows the Spanish term for MRI.

5 Confidence and Knowledge 90% 80% 70% 10% Gain in Confidence, 20% Gain in Knowledge Knowledge 86% Confidence 83% Confidence 73% Knowledge 66% A student who has more confidence to perform a task is more likely to do it successfully if that confidence is balanced with knowledge and skill. Before training, pre-test scores indicated that students were confident overall but needed help with technical vocabulary, basic information about interpreting and broad knowledge about medical topics. After 60 hours of training, students demonstrated a 10% gain in confidence and a 20% gain in knowledge. 60% Pre Post Confidence Gain Scores by Category 8% 9% 11% 11% 13% 13% Confidence Category # of Items Pre Post Gain Interpretation 5 70% 78% 8% Position & Gaze 5 77% 86% 9% Ethics 8 74% 85% 11%* Advocacy 2 73% 83% 11%* Language 3 67% 80% 13% Assertiveness 3 70% 83% 13% Interpretation Position & Gaze Ethics Advocacy Language Assertiveness Knowledge Gain Scores by Category 17% 22% 34% Knowledge Category # of Items Pre Post Gain Tech Vocab I 6 85% 90% 5% Tech Vocab % 88% 13% Medical 13 69% 86% 17% Interpretation 12 71% 93% 22% Tech Vocab % 69% 34% 13% 5% Technical Vocab 1 Technical Vocab 2 Medical Interpretation Technical Vocab 3 n=238 *Numbers may not add up due to rounding.

6 Who takes SBA? We studied 238 SBA students. The group included significantly more women (87%) than men (13%). Education 42% some college 28% Bachelor s or Master s degree 16% Associate s degree 14% never attended college 1% MD or PhD Experience 1 year or less: 13% 2 9 years: 54% years: 12% 20 years or longer: 6% don t work in a health care setting: 14% Work Setting 64% hospital 6% doctor s office 1% health department 1% emergency response 27% other Age and Language Age Range Current Age Started Learning Spanish Started Learning English 0 5 years old 6 10 years old years old 5% are under 20 years of age 76% 4% 16% 46% 24% 19% years old years old years old 45% 25% 13% 2% 2% at 31 years old or older 7% 3% at 31 years old or older Jorge Masuello, MD and Barbara Rayes We were impressed with the caliber of the curriculum. It s well planned, easy to understand, professional. The handouts are great! Brenda Shepherd-Vernon, Children s National, Washington, DC

7 Partner Children s Hospitals Trained instructors are actively working to implement the program in Albany, NY, Austin, TX, Boston, MA, Madera, CA and San Diego, CA. SBA has been established at: Palmetto Health Richland Children s Hospital Children s Hospital Driscoll Children s Hospital Children s Medical Center Texas Children s Hospital Children s Mercy Hospitals & Clinics Childrens Hospital University of Minnesota Children s, Fairview Children s Hospital & Research Center Children s Hospital Temple University Health System Children s Medical Center Phoenix Children s Hospital Children s Hospitals & Clinics of Minnesota Primary Children s Medical Center Children s National Medical Center Columbia, SC Columbus, OH Corpus Christi, TX Dallas, TX Houston, TX Kansas City, MO Los Angeles, CA Minneapolis, MN Oakland, CA Omaha, NE Philadelphia, PA Phoenix, AZ St. Paul, MN Salt Lake City, UT Washington, DC Success and Innovation at Partner Hospitals Dallas piloted the course in one area of the hospital first, then expanded to include other areas; almost 80 students were trained in the first year in four consecutive classes. The Minneapolis-St. Paul partners collaborated through a multi-hospital consortium. Children s Hospital in Omaha, Nebraska co-hosted a statewide teleconference workshop on Extreme Interpreting. Partner hospitals tried various formats and schedules for the course, including nights, weekends, and self-study modules, which reduced impact on compensated time off expense. Temple University Health System piloted a jump-start version of the program, teaching for two intensive weekends and holding monthly follow-up classes. Children s Mercy Hospitals & Clinics of Kansas City showed commitment to sustainability. As their trained instructor moves to another state and connects with a new children s hospital, Children s Mercy will be training a new instructor in MIP Phase 2. Primary Children s Medical Center of Salt Lake City is highly successful with volunteer medical interpreters who have served on missions in Spanish speaking countries. Phoenix Children s Hospital developed objectives and group practice specific to three types of learners: heritage speakers (who grew up speaking both languages), native Spanish speakers, and native English speakers. Several partner hospitals invited foreign-trained physicians to help teach medical topics. Childrens Hospital Los Angeles developed Continuing Education Units for California nurses taking the SBA course. The average Spanish-speaking patient population in partner hospitals is 25%. The average number of open staffed beds per partner hospital is 440. The range in partner hospital size by open bed count was 200 to 1036.

8 Collaborations Phoenix Children s Hospital became one of ten collaborating hospitals for the Robert Wood Johnson Foundation Speaking Together program aimed at identifying, testing, and improving the ways hospitals deliver language services. Phoenix Children s is focusing on communication quality improvement initiatives specifically involving children with diabetes. [Supervisors] are very happy with the capability that the interpreters have right now, understanding the condition of the patient, following the treatment plan. They are seeing a big improvement in that area. Lucy Cabal, Primary Children s, Salt Lake City Thank you We are grateful to the global organization Ronald McDonald House Charities, Inc., Phoenix Children s Hospital, each instructor, and each supporting organization. For general information or to become a partner hospital or instructor candidate in the next phase of the national Medical Interpreter Project, please contact Erin Rodda-Kuroiwa (602) erodda@phoenixchildrens.com Phoenix Children s Hospital developed version 2.0 of the Child Hospitalization Communication, Quality and Safety Survey (CHCQSS) and surveyed 60 Spanish speaking and 30 English speaking patient families to expand on a research project originally funded by the Commonwealth Fund called Quality, Patient Safety and Hospital Care for Latino Children: Addressing Parent and Provider Communication Challenges. Phoenix Children s Hospital Language Services Center, collaborating with Cross Cultural Communications, LLC, co-produced and presented an interactive workshop titled the Tug of War about bilingual employees serving as interpreters at the international Quality Health Care for Culturally Diverse Populations Conference in Seattle, October The Project collaborated with the national program office and local Arizona affiliate of the Epilepsy Foundation to produce high quality instructional materials for the Spanish Bilingual Assistant course which were used and evaluated by partner hospitals. Most significant improvement was noted in knowing not to put an object in the mouth of a person having a convulsion, with a 40% increase in students answering correctly. National Council on Interpreting in Health Care produced the national Code of Ethics and Standards of Practice for Interpreters in Health Care which are a part of the Project curriculum and were accepted by all instructors and partner organizations. The Joint Commission Hospitals, Language & Culture project reported how 60 hospitals across the nation are providing health care to diverse populations in order to better understand the current state of practice. No children s hospitals were included in the study. The report shares emerging practices and references this Project