AREAS OF RESPONSIBILITY

Transcription

1 Applies To: All HSC Hospitals Component(s): All Inpatient and Outpatient services Responsible Department: Interpreter Language Services Procedure Patient Age Group: ( ) N/A (X ) All Ages ( ) Newborns ( ) Pediatric ( ) Adult DESCRIPTION/OVERVIEW This procedure provides information about and expectations for access to interpreter services, either by telephone, video or face-to-face, during all hours of operation for Limited English Proficient (LEP) persons. For purposes of this procedure, an individual whose primary language is American Sign Language (ASL) will be considered to be LEP. Additionally, an interpretation is defined as a three-way conversation between a provider and a patient or family member etc., with a qualified interpreter providing language support to both parties. REFERENCES Patient Rights and Responsibilities, revised January 2017 Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000(d) Title IX of the Education Amendments of 1972, 20 U.S.C et seq Age Discrimination Act of 1975, 42 U.S.C et seq. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C Patient Protection and Affordable Care Act of 2010, Section 1557, 45 CFR 92 eff July 18, 2016Institute of Medicine (U.S.) Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press. The Joint Commission (2007). Hospitals, Language and Culture: A Snapshot of the Nation: Exploring Cultural and Linguistic Services in the Nation's Hospitals. Washington, D.C.: The Joint Commission The Joint Commission (2014). Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals. Washington, DC: The Joint Commission. U.S. Department of Health and Human Services, Office of Minority Health. (2016). National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: Compendium of State-Sponsored National CLAS Standards Implementation Activities. Washington, DC: U.S. Department of Health and Human Services. AREAS OF RESPONSIBILITY All HSC staff and providers are responsible for adherence to this procedure. UNM Hospitals and the Interpreter Language Services Department has responsibility for oversight of the program and for managing interpreting and translation resources. PROCEDURE 1. LEP Assessment and Primary Language Identification 1.1. Staff members should ascertain as soon as possible whether a patient, or family member or companion involved in making decisions regarding a patient s plan of care, is a LEP person, and if so, the primary language spoken by that individual. Page 1 of 7

2 1.2. Under ordinary circumstances, this assessment should take place during the scheduling, pre-admissions, or any point of intake It is appropriate for employees to initiate inquiries regarding the person s language proficiency in order to determine interpretation needs In situations where the primary language spoken is not readily known, the telephone interpretation service utilized by the Hospitals may assist in language identification. 2. Recording of LEP Information 2.1. At the time the patient presents for service, the primary language of every LEP patient shall be ascertained and recorded. A self-report demographics form may be provided to the patient to ascertain language preference, need for an interpreter, and race/tribal affiliation data. The URL to access the form in multiple languages and large print is attached to this document The LEP patient s primary language and need for an interpreter will be recorded in the electronic health record (EHR) To alert staff members to potential language assistance needs an I speak card may be available Interpreters employed by the Hospitals will document their patient encounters in the EHR. Interpreter notes will address the type of interpretation provided (e.g. exam, medical history, interpretation of written materials, and patient education.) Employees who use vendor interpreters via phone, video or in-person shall document the interpretation event in the EHR. 3. Informed Right to Hospital Provided Interpreter 3.1. Signage provided at main points of entry informs patients and family members or companions of the right to an interpreter at no charge. When a patient or a family member or companion involved in making decisions regarding a patient s plan of care is first assessed as being LEP, hospital personnel shall offer interpretation services. There will be no additional charge to the patient, family member or companion for this service. A translated patient demographics form may be used to inform the patient of his/her rights If the LEP person is unable to read notices or documents, hospital personnel will arrange to have the contents of the notice communicated to the LEP person through a hospital-provided interpreter Information on the availability of language assistance through or by UNM Hospitals will be available on web pages accessible to members of the general public and on posters located at main points of entry. 4. Use of Family Members or Patient Provided Interpreters 4.1. Hospital-provided interpreters are part of the care team, and as such should be present during medical interpretation with LEP patients, when direct care in the patient s language cannot be given by the provider The hospital will not use family members or other non-qualified interpreters except in unusual circumstances. If the LEP patient requests their own interpreter in lieu of a hospital-provided interpreting service, the refusal and request will be documented in the patient s record, along with the name, DOB and relationship of the individual to the patient Page 2 of 7

3 The individual must be an adult (age 18 and up) except in certain emergency situations where there are no other options available, and if this occurs, the duration shall be for a short period of time until a video, in-person or telephonic interpreter can be obtained In the event hospitals staff or providers have reason to believe that an LEP person s preferred interpreter is hampering effective communication, the hospitals will provide interpreter services to support the provider and/or hospital staff The accompanying person may remain at the patient s request, but the hospital will not be responsible for any sort of payment to this individual. 5. Circumstances Requiring Interpreter Services. Interpreter services should be provided in certain circumstances when necessary for effective communication in connection with treatment rendered by the Hospitals to a patient and/or in order for the patient to receive the full benefit of the Hospitals services. Examples of circumstances in which interpreters should generally be used, in any modality (in-person, video or phone) include the following: 5.1. Determination of a patient s medical history or description of ailment or injury; 5.2. Provision of patient s rights, informed consent or permission for treatment; 5.3. Explanation of living wills or powers of attorney (or their availability); 5.4. Explanation of diagnosis or prognosis of an ailment or injury; 5.5. Explanation of procedures, tests, treatment, treatment options or surgery; 5.6. Explanation of medications prescribed including dosages as well as how and when medication is to be taken and any possible side effects; 5.7. Explanation regarding follow-up treatment, dietary restrictions, therapy, test results or recovery; 5.8. Discharge instructions; 5.9. Provision of psychiatric evaluation, group and individual therapy, counseling and other therapeutic activities, including grief counseling and crisis intervention; Resolving billing or insurance issues that may arise; Classes concerning birthing, nutrition, CPR, weight management, etc.; Informational presentations for patients or the public sponsored or contracted for by UNMHSC Clinical Operations; Spiritual counseling provided at the University Hospitals; Blood donation or apheresis. 6. Emergencies: In an urgent or emergent situation where the patient s medical condition might be compromised by waiting for an interpreter to arrive before beginning assessment and treatment, and where use of a telephonic interpreter services is not appropriate or available, staff should render any necessary and appropriate medical treatment. Employees should use their best efforts to provide the most effective communication possible until such time as a language interpreter arrives. Page 3 of 7

4 7. Interpreter Resources 7.1. On-Site Medical Interpreters (Spanish, Vietnamese, Arabic, Navajo, American Sign Language) UNM Hospitals employs on-site Spanish, Vietnamese, Arabic, Navajo and American Sign Language interpreters who serve all HSC Hospitals and Clinics. Interpreters may be reached by contacting the Interpreter Language Services Department or by checking the daily AMION schedule for dispatch desk or after-hours cell phone numbers UNM Hospitals contracts with external agencies to provide on-site or video American Sign Language interpretation. Contact the Interpreter Language Services Department to arrange for an in-person Sign Language interpreter. Use video interpreter equipment 24/7 to request video interpretation on demand. In-person ASL interpretation will be prioritized to deaf/blind patients and others with medical circumstances that require in-person interpretation support UNM Hospitals has deployed video interpretation equipment throughout offsite clinics and on-site diagnostic or inpatient units to support language needs in addition to ASL. Requests for languages not supported via video will rollover to a contracted telephonic interpretation vendor 24/ Telephone Interpreter Service (all languages except American Sign Language). UNM Hospitals has contracted with vendors to provide medical interpretation 365 days, 24 hours a day. The telephone interpreter service provides interpretation in over 200 languages and may be reached by dialing 2-TALK (2-2855) from any hospital phone or by dialing The telephone interpreter service should be utilized when the requested language is not available from an on-site interpreter or the on-site interpreters are unable to respond to the request in a timely manner Employee Interpretation Employees who have passed the language-qualifying test administered by the Hospitals may interpret medical information. Such employees are designated as qualified dual role interpreters. After 7/1/2008, new dual-role interpreter employees will pass at the senior level for testing, attend required training, and shadow an interpreter Educator/Preceptor for skills validation prior to beginning to serve in a medical interpreter role. Existing qualified dual role interpreter employees will be grandfathered. Beginning in 2017, qualified dual role employees and staff interpreters shall receive structured continuing education and will be periodically shadowed for skills validation The Interpreter Language Services Department maintains a list of employees deemed qualified to serve as interpreters and who are able to provide on-site interpreting The list of qualified employee interpreters is accessible through a link on the UNM Hospitals Intranet homepage Hospitals personnel may consult the list and locate an interpreter who is listed by name, shift, language, and department It is the responsibility of any employee providing interpretation services to complete and sign the Interpreter Documentation form Page 4 of 7

5 in the patient s electronic medical record in Cerner Millennium under Ad Hoc Charting. If the interpretation service was for a person other than a patient, the Employee Interpreter Services Utilization form should be filled out and submitted to the Interpreter Language Services Department As part of providing assistance to patients, any HSC Clinical Operations employee may conduct non-medical conversations in a second language within the scope of his/her job position. A qualifying test is not required. Examples of conversational interpretation would include: scheduling an appointment, answering questions regarding hours of operation, screening for financial assistance, or providing directions Translating Written Communications All written translation of UNMHSC documents will be coordinated through Interpreter Language Services Department. Requests may be transmitted via attachment to Translation@salud.unm.edu UNMHSC employees should arrange to have an interpreter provide a sight translation when it is necessary to convey information contained in a document when no translated version is available. 8. Training: All UNMHSC employees providing medical care or other services to LEP persons should be knowledgeable concerning the nature and scope of the language assistance services provided by the Hospitals, and the procedures through which they may access those services UNMHSC Clinical Operations employees whose routine duties include interactions with the public will be provided with training on the scope and nature of available language assistance services and the specific procedures through which such services can be accessed at the employee s work location. 9. Monitoring Access to Language Assistance Services 9.1. Interpreter Language Services will monitor access and utilization of the language interpreter and translation services provided by the UNMHSC At least every three years, the UNMHSC will evaluate the interpreter program based on: Current LEP populations in service area or population affected or encountered Frequency of encounters with LEP language groups Availability of resources, including technological advances and sources of additional resources Whether existing assistance is meeting the needs of LEP persons Whether staff knows and understands the Language Interpreter policy and how to implement it Whether identified sources of assistance are still available and vital. 10. Patient Grievance Process Page 5 of 7

6 10.1. LEP patients may utilize the UNM Hospitals grievance process to forward and request resolution to complaints or concerns The Manager of Interpreter Language Services has been designated as the Language Access Coordinator for UNMHSC. Any allegation of discrimination (beyond language services) may additionally be referred to the Director of Diversity Equity and Inclusion The Language Access Coordinator will receive and respond to questions and complaints regarding adequacy of language access services, in coordination with the UNMHSC Patient Advocate The UNMHSC Patient Advocate will include information regarding LEP access questions and concerns in the monthly report to the Executive Director, Care Management Services. This information will flow upward through Quality and the Committee on Excellence The use of this grievance process does not preclude LEP persons from filing a complaint of discrimination on the basis of national origin with the U.S. Department of Health and Human Services, Office for Civil Rights This information is additionally outlined on Patient Rights posters available at main points of entry into the hospitals and clinics. DEFINITIONS Limited English Proficient (LEP) An individual who primarily communicates in a language other than English and demonstrates a limited ability to read, speak, or understand English. Translation transcription of written documents from one language into another language. Interpretation - a three-way conversation between a provider and a patient or family member, etc., with a qualified interpreter providing language support to both parties. SUMMARY OF CHANGES Updated equipment and posters/signage language. Added definitions of Interpretation and Translation. Added information on Arabic Interpretation. Clarified training for staff. KEY WORDS Interpreter, language, LEP, Translation, Grievance RESOURCES/TRAINING Resource/Dept Internet/Link Interpreter Language Services Interpreter Training Class Interpreter Language Hospital Intranet click on Learning Central Services Cerner Millennium Interpreter Documentation Access Cerner Powerchart via Ad Hoc Charting select Interpreter tab. Form OPD and ILS Courses for Hospital Intranet click on Learning Central internal staff Translation request Translation@salud.unm.edu Request an Interpreter Page 6 of 7

7 Qualified Dual Role Employee Listing Order Equipment About Me Patient Demographics Intake Form and Training/Tipsheet Patient Rights Form 16.pdf DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Manager, Interpreter Language Services UH/Community Interpreter Advisory Committee Executive Director, Care Management Services Executive Director, Quality Consultant(s) Executive Director, Ambulatory Business Operations Director, Ambulatory Support Operations Director, Diversity Equity and Inclusion Dept of Health and Human Services, Office of Civil Rights Committee(s) Ambulatory Executive Committee Nursing Executive Committee, UNMH PPG Committee Y Official Approver Kori Beech, Administrator, Ambulatory Services Y Official Signature On SharePoint 4/11/2018 Effective Date 4/11/2018 Page 7 of 7