Legal and Practical Implications of the
Limited-English Speaking (LEP) Patient
Gem P. Daus, M.A.
Executive Director, NCHIC...
I. Understand terminology & what an interpreter does
II. Understand the role of NCIHC
III. Understand the legal & other re...
 Limited-English Proficient (LEP)
 Bilingual
 Translation
 Interpreting
 Sight translation
 Limited-English Proficient
◦ a legal concept referring to a level of English proficiency that
is insufficient to ensure ...
 Translation
◦ the conversion of a written text into a corresponding written
text in a different language.
 Interpreting...
 Sight translation
◦ oral rendition of written text from one language into
another language, usually done in the moment
...
7
 Interpreting is a triadic job
provider + LEP + interpreter
 Facilitate communication between individuals
 Interpreter says exactly what is being said by both
parties
 Transparent...
 Converts language by meaning, uses same tone, level
of vocabulary (register)
 Clarifier or broker if s/he feels there m...
 familiarity with regionalisms and slang in both
languages;
 ability to identify differences in meaning due to
dialects/...
 extensive knowledge of the vocabulary and
terminology related to diagnosis, prevention,
treatment and management of illn...
 Active listening skills
 Message conversion skills
 Clear and understandable speech delivery
 Memory
 Note taking
12
13
 Telephonic or Over-the-Phone-Interpreting (OPI)
 Video relay interpreting
◦ Useful for Languages of Lesser Diffusion
◦ ...
I. Understand terminology
II. Understand the role of NCIHC
III. Understand the legal requirements for providing
care to a ...
 1994 – first conference on medical interpreting (Seattle)
 2000 – incorporated as 501(c)3
 Multidisciplinary membershi...
2004
National Code of Ethics for Interpreters in Health Care
– guiding principles and values governing conduct;
shoulds
20...
 Objective
◦ To acknowledge the inherent dignity of all parties in the
interpreted encounter
 Code of Ethics
◦ The inter...
 Provide consistency in performance of role, leading
to a dangerous potential for incomplete and
inaccurate communication...
20
2001-2010
Published 13 working papers
Open calls/Webinars:
Mental Health Interpreting
Vicarious Trauma/Interpreter S...
2011
National Standards for Healthcare Interpreter Training
Programs
Collaborate with the Certification Commission for
Hea...
 Assure that the ethics and protocols identified as
fundamental by the interpreting community are
reflected in standard-b...
I. Understand terminology
II. Understand the role of NCIHC
III. Understand the legal requirements for providing
care to a ...
A. Civil Rights Act of 1964, Title VI
B. Executive Order 13166
C. HHS OCR Guidance
D. CLAS Standards
http://www.lep.gov/fa...
 Individuals who do not speak English as their primary
language and who have a limited ability to read, write,
speak, or ...
* Language = “national origin”
“No person in the United States shall, on the
ground of race, color, or national origin, be...
 Federal courts and agencies have interpreted
discrimination by national origin to include language.
In other words: If s...
“By the authority vested in me as President by the
Constitution and the laws of the United States of
America…it is hereby ...
 President Clinton issued it in August 2000.
 President Bush re-affirmed it during his
administration.
 President Obama...
Federal agencies must:
 Plan for their own programs to meet Title VI
standards
 Issue LEP guidances to their grantees
It...
Federal agencies must make sure that:
 Federal fund grantees meet Title VI standards
 Community members and organization...
“No person may be subjected to discrimination
on the basis of national origin in health and
human services programs becaus...
 The Guidance is a document that sets a standard
for how to comply with Title VI.
 It does not establish any new require...
A recipient* is any public and private entity receiving
federal funds, including:
State, county, and local health and
welf...
A recipient must:
 Provide language assistance to LEP persons, to make
sure that they have equal access to programs and
s...
A recipient cannot do the following towards LEP
persons:
• Limit the scope or lower the quality of their
services
• Delay ...
 OCR uses a 4 factor analysis to “test” if a recipient
is complying with Title VI. The factors are:
◦ Number or proportio...
 Recipients should make sure patient knows that
an interpreter is available for free.
 Possible options for interpreting...
Interpreters should:
◦ Be proficient in English and the non-English language.
◦ Know special terms (such as medical, legal...
 If the recipient repeatedly uses a written material
with LEP persons, it should translate that material
into non-English...
 Vital documents are those that affect one’s
legal rights or obligations. For example:
◦ Application and enrollment forms...
The standards regarding
language access services
(numbers 4 through 7) are
based on Title VI!
 The Office of Minority Health (OMH) issued these standards
in 2000.
 They are the first national standards for cultural...
 Offer and provide language
assistance services, including
bilingual staff and interpreter
services.
Provide these servic...
 Provide both verbal offers
and written notices to
patients/consumers in their
preferred language.
 These notices should...
I. Understand terminology
II. Understand the role of NCIHC
III. Understand the legal requirements for providing
care to a ...
I. Understand terminology
II. Understand the role of NCIHC
III. Understand the legal requirements for providing
care to a ...
 Explain to the LEP how the interpreter will be used
 Speak directly to the LEP
 Use regular volume
 Keep a pace easy ...
 Make eye contact; use first person and speak directly
to the LEP
 Avoid slang; explain terminology that might be hard t...
 Ask LEP to bring own interpreter
 Ask another patient to interpret
 Ask a family member to interpret
 Ask a minor to ...
 No set interpreter-to-patient ratio
 One example
◦ For dental, the beginning (when the plan for the encounter is
laid o...
 On-site
◦ New patient visit
◦ Exams
◦ Children 7 and under
◦ First time a patient has dental work done
◦ Difficult proce...
53
 Gem P. Daus
 gdaus@ncihc.org
 info@ncihc.org
 www.ncihc.org
54
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Legal and Practical Implications of the Limited-English Speaking (LEP) Patient

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Legal and Practical Implications of the Limited-English Speaking (LEP) Patient

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  • Sight Translation and Written Translation: Guidelines for Healthcare Interpreters , www.ncihc.org
  • Note: Less than “ very well ” is not a universally accepted definition of LEP.
  • What does the third bullet mean? What is being guided by the guidance? How to comply with Title VI.
  • I’m going to focus on oral interpretation b/c that’s been focus of much of the national attention 1. A covered entity may expose itself to liability if it requires, suggests, or encourages an LEP person to use family members, minors, or friends May result in breach of confidentiality May have less than competent interpretation May result in less than full disclosure of needed information, diagnosis 2. However, a patient does ultimately have a right to use their own interpreter -- BUT ONLY AFTER: (1) the LEP person has been informed of their right to receive free language assistance; (2) she has declined & requests the use of her own interpreter; and (3) use of family member/ friend will not compromise effectiveness of service or violate confidentiality 3. Successful programs use a combination of all oral interpretation options
  • Add a slide spelling out abbreviation Office of Minority Health Culturally and Linguistically Appropriate Services
  • 3 rd bullet is a little redundanct. CLAS should define fair and effective treatment.
  • I’m confused. There are 4 clas standards for language access. But there are 6 bullets.
  • Legal and Practical Implications of the Limited-English Speaking (LEP) Patient

    1. 1. Legal and Practical Implications of the Limited-English Speaking (LEP) Patient Gem P. Daus, M.A. Executive Director, NCHIC March 18, 2011 UNC School of Dentistry 4th Annual Risk Management Seminar 1
    2. 2. I. Understand terminology & what an interpreter does II. Understand the role of NCIHC III. Understand the legal & other requirements for providing care to a limited-English proficient patient IV. Understand the cultural differences that can and do impact care V. Considerations for an effective interpretation and translation program in your dental practice.
    3. 3.  Limited-English Proficient (LEP)  Bilingual  Translation  Interpreting  Sight translation
    4. 4.  Limited-English Proficient ◦ a legal concept referring to a level of English proficiency that is insufficient to ensure equal access to public services provided in English without an interpreter [ASTM]  Bilingual ◦ a person who has some degree of proficiency in two languages. A high level of bilingualism is the most basic of the qualifications of a competent interpreter but by itself does not insure the ability to interpret.
    5. 5.  Translation ◦ the conversion of a written text into a corresponding written text in a different language.  Interpreting ◦ the process of understanding and analyzing a spoken or signed message and re-expressing that message faithfully, accurately and objectively in another language, taking the cultural and social context into account [ASTM]. ◦ Simultaneous, consecutive, relay (3 languages) ◦ Face-to-face, telephone, remote video
    6. 6.  Sight translation ◦ oral rendition of written text from one language into another language, usually done in the moment  Consecutive Interpreting ◦ oral rendition of two language with pauses at appropriate stopping places to allow for interpreting  Simultaneous Interpreting ◦ oral rendition of language with a short lag time as person is speaking  Dual-role interpreter ◦ a bilingual employee who has been tested for language skills, trained as an interpreter, and assumes the task of interpreter 6
    7. 7. 7  Interpreting is a triadic job provider + LEP + interpreter
    8. 8.  Facilitate communication between individuals  Interpreter says exactly what is being said by both parties  Transparent, must interpret everything that is being  Uses 3rd person, except when working with children 8
    9. 9.  Converts language by meaning, uses same tone, level of vocabulary (register)  Clarifier or broker if s/he feels there may be a barrier to understanding  Stops session to ask clarification or for speed  Pre-session with provider and LEP  Cultural broker, purpose is to facilitate impact culture may have on questions/responses 9
    10. 10.  familiarity with regionalisms and slang in both languages;  ability to identify differences in meaning due to dialects/regionalisms to ensure effective and accurate message conversion;  ability to communicate in all registers/levels of formality;  understanding of colloquialisms and idiomatic expressions in all working languages;  working knowledge of anatomy and physiology; 10
    11. 11.  extensive knowledge of the vocabulary and terminology related to diagnosis, prevention, treatment and management of illness and disease;  thorough understanding of key concepts in health care such as confidentiality, informed consent and patients’ rights;  thorough command of the vocabulary related to the provision of health care in both languages. 11 Competencies (2)
    12. 12.  Active listening skills  Message conversion skills  Clear and understandable speech delivery  Memory  Note taking 12
    13. 13. 13
    14. 14.  Telephonic or Over-the-Phone-Interpreting (OPI)  Video relay interpreting ◦ Useful for Languages of Lesser Diffusion ◦ Useful for speed ◦ Not as personal ◦ Not an option in some circumstances (ambulances)  Face-to-face interpreting encounter in trauma cases 14
    15. 15. I. Understand terminology II. Understand the role of NCIHC III. Understand the legal requirements for providing care to a limited-English speaking patient IV. Understand the cultural differences that can and do impact care V. How to construct, monitor and maintain an effective interpretation and translation program in your dental practice.
    16. 16.  1994 – first conference on medical interpreting (Seattle)  2000 – incorporated as 501(c)3  Multidisciplinary membership: Medical interpreters Interpreter service coordinators Educators/Trainers Clinicians Health Care Personnel Policy makers Advocates Researchers  Mission: to promote and enhance language access in health care in the United States.  www.ncihc.org info@ncihc.org 16
    17. 17. 2004 National Code of Ethics for Interpreters in Health Care – guiding principles and values governing conduct; shoulds 2005 National Standards of Practice for Interpreters in Health Care – what and how a competent interpreter does (accuracy, confidentiality, impartiality, respect, cultural awareness, role boundaries, professionalism, professional development, advocacy) 17
    18. 18.  Objective ◦ To acknowledge the inherent dignity of all parties in the interpreted encounter  Code of Ethics ◦ The interpreter treats all parties with respect.  Standards of Practice ◦ The interpreter promotes direct communication among all parties in the encounter. ◦ For example, the interpreter may tell the patient and provider to address each other, rather than the interpreter.
    19. 19.  Provide consistency in performance of role, leading to a dangerous potential for incomplete and inaccurate communication  Make health care providers and interpreters aware of the clinical and financial ramifications from using unqualified interpreters  Provide guidance when addressing ethical dilemmas during an interpreting encounter 19
    20. 20. 20 2001-2010 Published 13 working papers Open calls/Webinars: Mental Health Interpreting Vicarious Trauma/Interpreter Self-Care Best Practices Certification State policies (March 18, 2011, 1:00 p.m. EST)
    21. 21. 2011 National Standards for Healthcare Interpreter Training Programs Collaborate with the Certification Commission for Healthcare Interpreters (CCHI) on a national certification http://www.healthcareinterpretercertification.org/ 21
    22. 22.  Assure that the ethics and protocols identified as fundamental by the interpreting community are reflected in standard-based training  Help assure consistency and accountability in healthcare interpreter training programs  Define the role Standards of Training will play in national certification 22
    23. 23. I. Understand terminology II. Understand the role of NCIHC III. Understand the legal requirements for providing care to a limited-English speaking patient IV. Understand the cultural differences that can and do impact care V. How to construct, monitor and maintain an effective interpretation and translation program in your dental practice.
    24. 24. A. Civil Rights Act of 1964, Title VI B. Executive Order 13166 C. HHS OCR Guidance D. CLAS Standards http://www.lep.gov/faqs/faqs.html
    25. 25.  Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English.  Anyone who answers less than “very well” to the question on the U.S. Census Survey: How well do you speak English?
    26. 26. * Language = “national origin” “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” 42 U.S.C. § 2000d
    27. 27.  Federal courts and agencies have interpreted discrimination by national origin to include language. In other words: If someone discriminates against you because you can’t speak English, then it is a violation of your civil rights.
    28. 28. “By the authority vested in me as President by the Constitution and the laws of the United States of America…it is hereby ordered as follows:… “…each Federal agency shall … implement a system by which LEP persons can meaningfully access those services consistent with, and without unduly burdening, the fundamental mission of the agency.”
    29. 29.  President Clinton issued it in August 2000.  President Bush re-affirmed it during his administration.  President Obama reaffirmed it Feb 7, 2011
    30. 30. Federal agencies must:  Plan for their own programs to meet Title VI standards  Issue LEP guidances to their grantees It makes federal agencies plan for meaningful language access to their programs and activities.
    31. 31. Federal agencies must make sure that:  Federal fund grantees meet Title VI standards  Community members and organizations get a chance to speak to what the language access needs are
    32. 32. “No person may be subjected to discrimination on the basis of national origin in health and human services programs because they have a primary language other than English.” - Notice regarding language (1980)
    33. 33.  The Guidance is a document that sets a standard for how to comply with Title VI.  It does not establish any new requirements or mandates
    34. 34. A recipient* is any public and private entity receiving federal funds, including: State, county, and local health and welfare agencies Hospitals and clinics Nursing homes Senior Citizen Centers Managed care organizations Mental Health Centers Other programs that receive federal funds *When the Guidance says, “recipient” , it means a “recipient of federal funds”.
    35. 35. A recipient must:  Provide language assistance to LEP persons, to make sure that they have equal access to programs and services.  Apply the LEP guidance to all the programs in the recipient’s organization (even if HHS funds only directly support one program).
    36. 36. A recipient cannot do the following towards LEP persons: • Limit the scope or lower the quality of their services • Delay the delivery of their services unreasonably • Limit their participation in a program • Require them to provide their own interpreters or pay for interpreters.
    37. 37.  OCR uses a 4 factor analysis to “test” if a recipient is complying with Title VI. The factors are: ◦ Number or proportion - How many LEP persons are eligible to be served, or likely to be encountered? ◦ Frequency – How often do LEP persons come in contact with the program? ◦ Nature and importance – How important is the program, activity, or service to people's lives? ◦ Resources – What resources are available to the recipient? What will the costs be?
    38. 38.  Recipients should make sure patient knows that an interpreter is available for free.  Possible options for interpreting services include: ◦ Bilingual staff Staff interpreters ◦ Contract interpreters Volunteer interpreters ◦ Telephone language line  Recipients must not require a patient to use friends, family or minor children for interpretation
    39. 39. Interpreters should: ◦ Be proficient in English and the non-English language. ◦ Know special terms (such as medical, legal jargon), as necessary ◦ Respect a patient’s rights to confidentiality and to impartial interpreters ◦ Understand the role of interpreter (such as ethics and practices).
    40. 40.  If the recipient repeatedly uses a written material with LEP persons, it should translate that material into non-English languages that are regularly encountered.  Recipients should translate or communicate information in vital documents.
    41. 41.  Vital documents are those that affect one’s legal rights or obligations. For example: ◦ Application and enrollment forms ◦ Letters or notices re eligibility or changes in benefits ◦ Anything requiring a response ◦ Patient consent forms
    42. 42. The standards regarding language access services (numbers 4 through 7) are based on Title VI!
    43. 43.  The Office of Minority Health (OMH) issued these standards in 2000.  They are the first national standards for culturally and linguistically appropriate services (CLAS) in health care.  OMH designed the Standards to help organizations provide culturally and linguistically accessible services for all.  All patients should receive fair and effective CLAS and treatment
    44. 44.  Offer and provide language assistance services, including bilingual staff and interpreter services. Provide these services:  at no cost to each LEP patient/consumer,  at all points of contact,  in a timely manner, during all hours of operation.  Make sure interpreters and bilingual staff are competently providing language assistance to LEP patients/consumers.  Not use family and friends to provide interpreting services (unless the patient/consumer makes a specific request). Health care organizations should…
    45. 45.  Provide both verbal offers and written notices to patients/consumers in their preferred language.  These notices should inform patients/ consumers of their right to receive language assistance services.  Make available easy-to- understand patient-related materials.  Post signs in the languages of the commonly encountered groups, and/or groups represented in the service area Health care organizations should…
    46. 46. I. Understand terminology II. Understand the role of NCIHC III. Understand the legal requirements for providing care to a limited-English speaking patient IV. Understand the cultural differences that can and do impact care V. How to construct, monitor and maintain an effective interpretation and translation program in your dental practice.
    47. 47. I. Understand terminology II. Understand the role of NCIHC III. Understand the legal requirements for providing care to a limited-English speaking patient IV. Understand the cultural differences that can and do impact care V. Considerations for an effective interpretation and translation program in your dental practice.
    48. 48.  Explain to the LEP how the interpreter will be used  Speak directly to the LEP  Use regular volume  Keep a pace easy for interpreter to follow  Keep dialogue short (helps accuracy) 48
    49. 49.  Make eye contact; use first person and speak directly to the LEP  Avoid slang; explain terminology that might be hard to understand  Have patient sign waiver if they refuse an interpreter  Have interpreter stand-by if LEP refuses an interpreter 49
    50. 50.  Ask LEP to bring own interpreter  Ask another patient to interpret  Ask a family member to interpret  Ask a minor to interpret  Ask a non-qualified staff member to interpret 50
    51. 51.  No set interpreter-to-patient ratio  One example ◦ For dental, the beginning (when the plan for the encounter is laid out) and end of the encounter (when findings are presented) ◦ At the beginning, the provider and patient set some gestures to help them move through the procedure smoothly. ◦ If there is an urgent need to communicate during the session, the dental assistant simply goes down the hall and gets the interpreter to come back to that area for a bit and provide language support.
    52. 52.  On-site ◦ New patient visit ◦ Exams ◦ Children 7 and under ◦ First time a patient has dental work done ◦ Difficult procedures ◦ Highly anxious patients  Remote ◦ established patients on a treatment plan
    53. 53. 53
    54. 54.  Gem P. Daus  gdaus@ncihc.org  info@ncihc.org  www.ncihc.org 54

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