Language Services in Healthcare- Disparities in Access

LANGUAGE SERVICES IN HEALTHCARE: DISPARITIES IN ACCESS
MSA 699 Project Report
Submitted in Partial Fulfillment of Requirements
For the Degree of
Master of Science in Administration
(Concentration is Healthcare Administration)
By
Megan Burgess
609356
CENTRAL MICHIGAN UNIVERSITY
Instructor:
Dr. Lathan III
December 14, 2015

Executive Summary
America is a country with a diverse population. A diverse population equates to diversity
in healthcare. In order to provide adequate healthcare to limited English proficient it is
imperative to provide appropriate language services. Language services are any type of
interpreting service, such as: professional interpreters, translated documents, and interpreters via
videoconferencing or telephone. However, there is a disparity in the services available to
patients.
Not providing language services can result in grave consequences for the patient. Without
proper communication a patient is not able to accurately describe his or her symptoms and the
physician is unable to make a proper diagnosis. Patients are not able to understand medication
instructions or physician instructions. In order to prevent these consequences it is necessary for
healthcare organizations to provide language services.
This research analyzes four separate sources relating to language services in healthcare.
These sources relate to different aspects of language services in healthcare. This makes it
possible to analyze language services in different locations and in different organizations. From
this it is possible to make recommendations for changes to make language services in healthcare
more accessible and effective. It also brings other areas of language services in healthcare that
need further research to light.

Table of Contents
Page Number
Chapter I – The Problem
Introduction……...………….………………………………1
Background of Problem………………………….…………2
Purpose of Study..…………………………………..………3
Research Objective…………………………………………4
Assumptions…………...…………………………………...5
Theoretical Framework…………………………………….5
Scope / Delimitations………………………………………7
Chapter II – Review of Related Literature
Introduction to Literature…………………………………..5
Presentation of Literature
Effects of language access disparities on healthcare
quality………………………………………………8
Current types of language services………………..10
Why language services are not utilized……………14
Recommendations to improve language services....15
Summary of the Literature………………………………...17
Chapter III - Methodolgy
Research Methodology……………………………………20
Sample…………...………………………………………..20
Data Processing and Analysis………………………….....21
Methodological Assumptions…..………………………...21

Methodological Limitations……………………………...22
Chapter IV – Findings
Data Analysis Introduction………………………………23
Data Presentation and Analysis
Effects of language access disparities on healthcare
quality……………………………………………23
Current types of services available………………26
Why language services are not utilized………….28
Recommendations to improve language
services…………………………………………..31
Chapter V – Summary, Conclusion, Recommendations
Summary…………………………………………………35
Conclusion……………………………………………….36
Recommendations……………………………………….37
References……………………………………………………….39-42

Access to Language Services Disparities in Healthcare 1
Chapter I
The Problem
Introduction
Healthcare is a very unique industry. It’s an industry that must conform to each consumer
based on that consumer’s needs, wants, and beliefs. One of the most important aspects of
successfully utilizing the healthcare industry is for the consumer to fully understand his or her
diagnosis, treatment plan, and prognosis in order to make an informed decision. For many
Americans this is not an easy option. According to the 2011 US Census over 60 million
Americans spoke a language other than English at home (Ryan, 2013). That is a large population
of Americans that have the potential to not receive the best healthcare possible because they
cannot understand their physician or other healthcare professionals.
Medicine has a language all its own, and is even hard for English speaking patients to
fully comprehend if they do not have a medical staff that takes the time to fully explain it. With
hospitals running short on staff and physicians having to fit in more and more patients to their
schedule everyday, their time spent with patients is decreasing. However, in order to give the
highest level of care physicians must ensure that they are properly informing their patients of
their conditions and answering all questions fully. In order to this with limited English proficient
patients (LEPs) it is vital that some type of interpreting service be utilized. There are many
different interpreting services available to healthcare professionals, however, these services may
not be readily accessible or easy to use. Healthcare professionals may not even have training on
these services or knowledge of their existence.

With the passing of the Patient Protection and Affordability Care Act there are going to
be many more patient accessing and utilizing the healthcare system. It is imperative that
hospitals and physician offices reevaluate and implement changes to their policies regarding
language services for their patients to ensure that every patient receive appropriate and prompt
professional translation services.
Background of Problem
Healthcare is an industry that everyone will need to utilize at some point in his or her life.
In the United States there are many issues associated with healthcare, such as: affordability,
accessibility and quality. Another issue that is on the rise is culturally competent healthcare
organizations. Healthcare is a very personal and unique industry. Two patients with the same
ailments may need to be treated in different ways because of their culture and beliefs. Being able
to provide culturally competent healthcare is something that every healthcare provider needs to
do. Cultural competence includes being aware of the 12 community essentials. The 12
community essentials are the foundation for cultures, and communication is number two on the
list (Killen, 2013).
The United States has a very diversified population that requires personalized healthcare.
It is important that the healthcare industry remain diversified and accountable to all patients, no
matter the language they may speak. Being culturally competent is no easy feat for healthcare
organizations and needs improvement. Providing language services is a right guaranteed by Title
VI of the Civil Rights Act in all health care organizations that receive federal funds (Tang,
Kruger, Quan, & Fernandez, 2014). However studies have shown that physicians “reported that

it was routinely their practice to “get by” without a professional interpreter win hospital
encounters with LEP patients, reserving professional interpreter use for “high stakes” hospital
encounters” (Tang et al., 2014, p. 1785). The study defines “high stakes” cases as patients
making decisions such as advanced directives or the initiation of chemotherapy (Tang et al.,
2014). This is a direct violation of Title VI, as it mandates every patient be provided with
language services, not just “high stakes” cases.
Purpose of the Study
This research will be helpful to any diversity department in a healthcare organization.
Any recommendations and information in this research could have the potential to increase
successful communication between healthcare providers and patients, which could help increase
patient satisfaction. Increasing successful communication could also lead to less complications
and possibly reducing readmissions. This research will also be helpful to healthcare
organizations that receive federal funding or are accredited by quality organizations such as The
Joint Commission, Healthcare Facilities Accreditation Program, or hospitals that are Magnet
Certified. In order for healthcare organizations to receive federal funding or continue to be
certified, they need to meet certain language services standards.
Language access disparities can also affect risk management, patient safety, and legal
departments of a healthcare organization. If a patient is not given the proper access to
interpretation services and the breakdown in communication leads to a medical error, the
organization would be opening itself up to a legal dispute. Language access disparities are a

liability for any healthcare organization, and could result in lawsuits. That means that language
access disparities require the attention of various departments in a healthcare organization.
This research is important to all patients who speak little to no English. In order for these
patients to receive quality care they need to have access to interpreter services that will allow
them to communicate their symptoms and current health status to caregivers. Physicians will
then be able to order the proper tests, diagnose, and treat the patient. If there is no proper
communication between patients and physicians, unnecessary tests could be ordered and patients
could be misdiagnosed. It is also imperative that patients completely understand their discharge
and medication instructions. If patients do not understand, major complications could occur and
readmission could be necessary. Healthcare organizations need to be prepared to properly treat
patients who do not speak English in order to avoid complications and unnecessary costs.
ResearchObjective
With the advances and availability in interpreting services it is important to examine
whether or not these resources are being used and how available they are to medical staff when
treating patients. Communication between physicians and patients is extremely important to
receive and provide successful healthcare. Being able to adequately explain symptoms and
situations to a physician and having that physician being able to understand and give instructions
that the patient can understand is a basic component of healthcare. Without this basic component
there could be many complications or misunderstandings. In an acute care setting, poor
communication could lead to readmissions. Poor communication could also lead to misdiagnosis
or no diagnosis when there should be.

Are there disparities in access to language services in patients in healthcare? In order to
answer this question four main topics will be discussed. The first is examining the effects of not
using language services. Second, the types of services available and the accessibility of these
services with are discussed. Third, utilization factor contributing to the use or lack of use of these
services will be researched. Finally, examining different approaches to eliminating language
access disparities and recommendations for healthcare organizations will be discussed. In order
to complete this study, a meta-analysis of pre-existing data will be used. There are many reports
and studies about language services in healthcare available to examine. It is important to
examine existing data to spot trends and themes and then draw conclusions and
recommendations from these trends and themes.
Assumptions
Because this study examines pre-existing data it is assumed that this data was accurately
reported and ethically obtained. It is also assumed that the authors of the various reports and
studies did not insert their personal bias into the reports. It is also assumed that all of the reports
have the same basic definition of “limited English proficiency”.
Theoretical Framework
This research will follow the rationale that a disparity in the access of languages services
exists within the healthcare industry. Researching the causes and affects of language access
disparities in healthcare will allow for the formulation of a theory as to why disparities exist and
how to improve language disparities. It is expected that there are multiple variables that effect

the use of language services in healthcare. It is also expected that these variables can be
remedied or eliminated resulting in an improvement in language services access for LEP
patients.
Scope/ Delimitations
This research will not include the types of languages that are spoken in the United States
or the different cultures that exist. This research will not include how different cultures and
beliefs affect the healthcare needs of the population. This research is representative of the United
States and healthcare organizations within the country. It is not representative of other countries
and their healthcare practices.

Chapter II
Review of the Related Literature
Introduction to the Literature
Language access disparities are a very popular topic and many research articles can be
found on the subject. Sorting through all of the research brings to light four main sub-topics that
help make the research meaningful and easier to connect. The first sub-topic relates to how
language access disparities can actually affect the healthcare a limited English proficient (LEP)
patient receives. Patients who do not understand instructions or what type of information they are
being asked for can lead to life threatening errors. It can also lead to dissatisfied patients,
increased diagnostic testing, and poor health status. Children of LEP persons also receive poor
care because their parents do not understand what is being asked or what the treatment plan is for
their child.
The second sub-topic describes what types of language services are available and how
they are or are not being utilized in healthcare organizations. First, it is important to note that
language services are a right afforded to the population by the Civil Rights Act of 1964. Federal
law, state law, and accrediting agencies require that competent language services be provided at
no cost to the patient. There are different types of interpreting services available and caregivers
use a variety of aids to communicate with their patients. Some aids are easier and more
accessible than others, but that does not mean that they are the most effective.
The third sub-topic explores different reasons that language services are not used in
healthcare organizations. There are many times that services are available but not used, and this
is a very important issue that needs to be resolved in order to reduce healthcare disparities for

non-English speaking patients. Staff being unaware of available services is one of the biggest
issues organizations face. Cost of interpreter services is another issue that can lead to disparities.
The final sub-topic will explore possible solutions and resolutions to the problem.
Healthcare organizations need to continually assess their language services and the effective use
of those services. Educating their staff and following up often with staff about language services
will allow the organization to examine areas that need improvement. Collecting patient data from
the area the organization serves and then ensuring that the organization is prepared to serve its
population will also decrease language services disparities. Finally, recently passed healthcare
reform laws aim to improve language disparities and strive to improve the healthcare received by
patients who speak little or no English.
Effects of language access disparities on healthcare quality.
Communication is a key component for providing healthcare. “High quality healthcare
requires the free and effective exchange of information between a patient and the patient’s
healthcare provider” (Teitelbaum, Cartwright-Smith, & Rosenbaum, 2012, p. 350). When
reviewing research it quickly becomes clear that language barriers in healthcare negatively affect
the quality and effectiveness of healthcare. LEP patients are at risk for, “reduced access to health
services, decreased satisfaction with care, poor understanding of instructions, longer hospital
stays, and increased risk of medical errors and misdiagnoses” (Jacobs, Leos, Rathouz, & Fu,
2011, pp. 1930–1931). “In addition, patients with English as a second language may be managed
differently by health care professionals and receive fewer recommended health care services than
native English speakers, regardless of their level of fluency” (Hines, Andrews, Moy, Barrett, &

Coffey, 2014, p. 13018). Language barriers also contribute to adverse medical events and an
increase in readmissions (Hines et al., 2014). LEP patients often receive more diagnostic testing
than is medically necessary (Torres, Parra-Medina, & Johnson, 2008). However, “the use of
professional interpreters has been shown to reduce such disparities and improve clinical
outcomes and patient satisfaction among LEP patients” (Tang et al., 2014, p. 1784).
Language barriers not only negatively affect results in a hospital setting but they also
negatively affect the overall healthcare of LEP patients. One study conducted by the
Commonwealth Fund found that “Hispanics who primarily speak Spanish are less likely to have
a regular doctor” (Language barriers inhibit CARE, 2003, p. 6). This study also found that
almost one-third of Spanish-speaking Hispanics reported their health status to be fair or poor.
This is more than twice the amount of whites and Hispanics who primarily speak English
(Language barriers inhibit CARE, 2003). LEP patients are also less likely to receive preventative
care such as yearly check-ups or mammograms (Teitelbaum et al., 2012). It has also been found
that LEP patients “were more likely to forgo needed medical care and less likely to have a
healthcare visit, compared to individuals who were proficient in English” (Teitelbaum et al.,
2012, pp. 350–351).
Not only do limited English speaking patients report poorer health, there are also
disparities in satisfaction when they do receive healthcare. When evaluating healthcare
satisfaction in two healthcare centers it was found that significant differences were present in the
areas of doctor-patient communication and help provided by office staff between Spanish-
speaking patients and bilingual or English-speaking patients. However, there was no significant
difference found in the areas of access to care, or promptness of care (O’Brien & Shea, 2011).

This leads one to conclude that the dissatisfaction is not with healthcare systems as a whole, but
rather with the ability for the patient and the physician or other medical staff to have a quality
and meaningful interaction that leads to positive outcomes and understanding.
The effect of LEP persons receiving poor healthcare also extends to their children. “LEP
parents were associated with triple the odds of a child having fair/poor health status” (Flores,
Abreu, & Tomany-Korman, 2005, p. 418). Children with LEP parents also have greater odds of
not being brought in for medical care (Flores et al., 2005). Pediatricians need to be able to
understand their patients’ parents in order to properly treat the patient because oftentimes the
patient is too young and may not understand what the physician is asking. Having proper
interpreter services in pediatric emergency rooms and offices is imperative for the well being of
the child.
Current types of language services.
Providing language services to LEP patients are not only helpful for the patient, it is also
a legal right reserved by the patient. There are many federal laws, state laws, and many
accrediting agencies require competent language services. Title VI of the Civil Rights Act of
1964 sets forth standards that are required to be met by entities that receive federal funding
(Chun, 2009). These standards focus on “Language Access Services” and include: availability of
interpreter services at no cost to the patient, providing information on language services,
assurance of competent interpreters and making patient materials and signage in languages that
are common to the area (Chun, 2009). Hospitals or other healthcare organizations that fail to
meet these standards could be fined and loose their federal funding (Torres et al., 2008). As of

2008, every state had passed laws requiring language assistance in healthcare organizations
(Snowden & McClellan, 2013). This means that healthcare organizations are required by many
laws to give competent language access to patients.
In order to assist healthcare organizations the U.S. Department of Health and Human
Services’ Office of Minority Health and the Office of Civil Rights developed the National
Standards for Culturally and Linguistically Appropriate Services (CLAS) (Hoffman, 2011).
CLAS standards four through seven are the mandated standards regarding language services that
must be met by all recipients of federal funding (Hoffman, 2011). The four standards are:
4. Health care organizations must offer and provide language assistance services,
including bilingual staff and interpreter services, at no cost to each
patient/consumer with limited English proficiency at all points of contact, in a
timely manner during all hours of operation.
5. Health care organizations must provide to patients/consumers in their preferred
language both verbal offers and written notices informing them of their right to
receive language assistance services.
6. Health care organizations must assure the competence of language assistance
provided to limited English proficient patients/consumers by interpreters and
bilingual staff. Family and friends should not be used to provide interpretation
services (except on request by the patient/consumer).
7. Health care organizations must make available easily understood patient-related
materials and post signage in the languages of the commonly encountered groups
and/or groups represented in the service area (Hoffman, 2011, p. 51).

By ensuring that these standards are met healthcare organizations are not only meeting federal
requirements but are also ensuring that they are providing the best possible care to LEP patients.
Language services are also imperative when obtaining proper informed consent. In order
for a patient to consent to any procedure, that patient must have all the information given to them
in a way they can understand. If proper informed consent is not received, the physician and the
healthcare organization would be liable for any treatment provided and could have lawsuit filed
against them. Performing procedures without informed consent is considered assault and battery
and carries heavy penalties (Teitelbaum et al., 2012).
Even though dissatisfaction with communication is present in healthcare, there are
language services in place in many hospitals and healthcare organizations. In order to understand
why there is still dissatisfaction an understanding of what types services are being used is
necessary. Written materials, interpreters, telephone assisted interpreters, and electronic
translation programs are the most common services offered in a healthcare organization.
However, many times these resources are not utilized. In fact, it was found that in 46 percent of
emergency department cases involving LEP patients, an interpreter was not used (Armada &
Hubbard, 2010).
A survey conducted on an oncology unit found that gestures and the use of family
members were the most frequently used forms of communicating with non-English speaking
patients (Pabon & Wisotzkey, 2013). While using a family member may be the easiest option, it
is not always the best option. It has been found that using a family member of a patient as an
interpreter can lead to miscommunication and medical errors (Tschurtz, Koss, Kupka, &
Williams, 2011). In fact the nurses included in the survey reported that they were often uncertain

if their patients “fully understood instructions or education they received”. It was also reported
that “completing an accurate assessment was difficult” and “care became task oriented rather
than therapeutic” (Pabon & Wisotzkey, 2013, p. 20).
It is important to understand that the use of ad hoc interpreters (family, friends or
untrained staff) has been proven to be ineffective (Tschurtz et al., 2011). Having a professionally
trained medical interpreter is very important. A trained medical interpreter is someone who has
been through formal exams and has been trained in the ethics and standards of practice of
medical interpreting (Tschurtz et al., 2011). Ad hoc interpreters have been found to interpret
inaccurately, omit information, and give the patient their own opinions. Ad hoc interpreters may
also lack medical terminology that could lead to miscommunications (Tschurtz et al., 2011).
Additionally, “the use of a minor for interpretation is highly unacceptable because of privacy
issues, the shift of power from the patient to the minor, and the potential for emotional trauma to
the minor” (Coren, Filipetto, & Weiss, 2009, p. 637). Even though it is discouraged, ad hoc
interpreters are the most frequently used resource. In fact, a study found that 80 percent of
caregivers admit to using an ad hoc interpreter when communicating with a LEP patient
(Tschurtz et al., 2011).
Why language services are not utilized.
There is clearly a discordance between language resources available and the use of these
resources (Tschurtz et al., 2011). A study conducted by Tang et al., discovered that "only 11

percent of resident physicians reported using professional interpreters 81-100 percent of the time
with hospitalized LEP patients" (2014, p. 1787). Tang et al. also concluded, "resident physicians
rated the quality of their communication with hospitalized LEP patients as worse compared with
their communication with similar English-speaking patients” (2014, p. 1787).
A large problem lies with healthcare staff not using the resources they have available to
them. There are various reasons for this. One study found that many staff members did not even
know what types of services were available for them to use. Other reasons staff did not use
services included: interpreters were not readily available, interpreting equipment was not
accessible and staff was unaware of how to access the equipment (Tschurtz et al., 2011).
“Evidence suggests that the easier it is for a physician or nurse to obtain and incorporate
language services into their care, the more likely the will include it as routine practice”
(Regenstein, Mead, Muessig, & Huang, 2009, p. 480). The time it takes to use language services
is another reason healthcare staff do not utilize these services. “Providers using an interpreter
during an outpatient visit may spend more time with a patient, which could reduce the volume of
patients seen in a session and reduce the revenue that is billed” (Blanchfield, Gazelle, Khaliif,
Arocha, & Hacker, 2011, p. 527). The use of family members as interpreters is often used instead
of professional interpreters because family members are readily accessible and less time
consuming (Pabon & Wisotzkey, 2013).
Cost is another reason many healthcare organizations do not provide proper language
services. “Despite the documented benefits of receiving language interpretation services, finding
the resources in an already financially constrained operating budget to pay for language
programs can be challenging for providers” (Blanchfield et al., 2011, p. 523). However, there are

numerous financial benefits to funding interpretation services. Providing medical interpretation
services is long-term cost effective in many ways. Reducing the risks of medical errors is a very
important benefit. Medical errors can cost the organization millions of dollars and could also
lead to sanctions and fines from the government and loss of accreditation. Investing in interpreter
services can lower the costs of care in emergency departments by reducing the use of excess
diagnostic testing (Jacobs et al., 2011).
Recommendations to improve language services utilization.
Improving access and utilization of language services will help to improve the overall
healthcare of non-English speaking patients. In order to do this it is important for healthcare
organizations to assess the use, effectiveness, and convenience of the language tools provided
(Tschurtz et al., 2011). This will help the organization find areas that they can improve and help
them form a plan to increase use, effectiveness and convenience. A written policy regarding
language services is necessary. This will help educate new staff and ensure uniformity
throughout the organization (Torres et al., 2008).
An important first step is to establish procedures for identifying LEP patients (Coren et
al., 2009). The US Census Bureau developed “I Speak” language identification cards that would
be beneficial for use in healthcare organizations (Coren et al., 2009). “An I Speak card lists a
phrase in numerous languages to all the patient to identify his or her preferred language” (Coren
et al., 2009, p. 637). It is also important for healthcare organizations to have an established
language services department (Regenstein, et al., 2009). The study completed by Regenstein, et
al., found that there was no consistency on the placement of language services departments

within various hospital structures, which suggests that hospitals struggle on how to fit language
services departments into their organizational model of delivering high quality care (2009). “To
the extent that language services can promote their department’s positioning or visibility within
the organization, the importance of the language services program will be more likely to take on
a central role in daily operations of the hospital” (Regenstein et al., 2009, p. 480).
Training physicians on using and working with interpreters could help improve language
access. Today very few physicians receive training on using interpreters and only 23 percent of
U.S. teaching hospitals provide that type of training (Armada & Hubbard, 2010). Many
physicians do not take the time to wait for interpreters and often use family members as
interpreters. Educating physicians on their legal duty to their patients to provide language
services could help reduce language disparities.
It would be useful for an organization to collect patient language data prior to admission.
This way the organization will know what types of resources they will need to properly care for
their potential patients (Armada & Hubbard, 2010). Having this patient data would also make it
easier to try and match patients with physicians who speak the same language. One study found
that when patients were matched with a physician that spoke the same language there were fewer
emergency room visits (Snowden, Teh-wei, & Jerrell, 1995). Recruiting interpreters or bilingual
caregivers that are trained in medical translations should also be a priority. This is especially true
for departments that see a high need for interpreters, such as emergency departments (Torres et
al., 2008).
The recently passed Affordable Care Act (ACA), “strengthens the bond between civil
rights law and healthcare” (Teitelbaum et al., 2012, pp. 364–365). The ACA does this by shifting

the focus from access to healthcare but access to appropriate healthcare. The ACA imposes
specific obligations for providers in regards to language services (Teitelbaum et al., 2012). “The
ACA treats language access as a foundational element of high quality healthcare” (Teitelbaum et
al., 2012, p. 372). However, it is important to ensure that all patients are receiving access to the
improvements that ACA is attempting to create. “Minority patients may face economic,
geographical, cultural, or language barriers that prevent them from fully engaging in
improvement efforts that require their attention” (Weinick & Hasnain-Wynia, 2011, p. 1839).
Summary of the Literature
The literature found supports that a problem of language access disparity exists in
healthcare. There are many healthcare issues that can arise from not using interpreter services.
LEP patients often forgo medical care or do not feel comfortable in healthcare situations because
they cannot understand their healthcare provider. LEP persons are less likely to have a primary
care physician and receive fewer preventative healthcare procedures.
With fewer LEP patients having primary care physicians, this results in many patients
seeking healthcare in an emergency settings. The lack in use of interpreting services results in
LEP patients having more diagnostic procedures, longer hospital stays, misdiagnoses, and
ailments going undiagnosed. All of these then lead costly medical bills, lawsuits, loss of federal
funding, fines, and possible loss of accreditations. LEP patients have a higher risk of
complications following hospital discharges due to not understanding medicine and follow up
instructions. All of this leads to poor quality of healthcare and patient dissatisfaction for LEP
patients.

It is recognized that interpreting services are very important aspect of healthcare.
Access to language services is a right to all persons seeking healthcare in the U.S., even if they
are not a legalized citizen, as set forth by the Civil Rights Act of 1964. Healthcare organizations
are required by federal law, state law, and accreditation agencies to provide language services at
no cost to the patient. There are many options available for interpreting services. These can
include: brochures, documents, phone interpreters, face-to-face interpreters, and devices, such as
iPads with interpreting applications.
Even though there are many different options for interpreting services, there are still
disparities in the access and use of these services. One of the largest problems is that staff is
unaware or unable to use these services. Sometimes waiting for an interpreter or finding the
interpreter phone takes too much time for caregivers, so they often rely on family members or
gestures to communicate with LEP patients. The use of family members or friends as interpreters
is an accessible and free form of interpretations. However, it is discouraged because it is possible
that miscommunication can still occur. Family members or friends may interject their own
opinions, omit pertinent information, or not understand medical terminology enough to translate.
This why using a formally trained medical interpreter is the most effective form of
communication between caregivers and LEP patients.
Many healthcare organizations make the misconception that offering high quality
interpreting services is too costly. However, the possible costs that could incur from not using
interpreting services are also severe. Lawsuits, fines and loss of federal funding are possible
costs that could arise from medical errors resulting from not using interpreting services.
Hospitals that accredited by agencies, such as The Joint Commission, could lose their

accreditation status. This could lead to the hospital losing their reputation for providing high
quality healthcare and ultimately result in a loss of business.
Improving access to language services is something that healthcare organizations need
to pay attention to constantly. Continually assessing the use of language services within the
organization will allow for improvements to be made. Educating staff on the importance of using
interpreter services and how to access those services is a key component to improving language
services. Educating staff not only during new hire orientation but also continually throughout
their career is also important. The ACA focuses on quality healthcare for persons, and will
hopefully make strides in reducing language access disparities by focusing language access as a
key component to quality healthcare. Healthcare is an ever-changing industry. In order to
provide quality healthcare to all patients, healthcare organizations need to recognize the
importance of interpreting services and instill that importance to all of their medical staff.

Chapter III
Methodology
ResearchMethodology
In order to further analyze the four subtopics raised in Chapter II a meta-analysis of four
previous studies has been completed. Each source has been published in various healthcare
journals and are all peer reviewed. When conducting the analysis each source was analyzed
based on the four sup-topics presented: effects of disparities in language access on quality of
care, current types of language services available, why language services are not utilized, and
recommendations to improve language services utilization. Trend and themes between the
articles were identified and analyzed.
Sample
The samples from each source vary, but are all healthcare related. The first source had a
sample of 23 hospitals providing acute care, rehabilitation, and psychiatric hospital services
within Florida’s Palm Beach, St. Lucie, and Martin counties. Each hospital was given two
questionnaires: the first was an administrative questionnaire that determined services the hospital
had available and the second questionnaire was for staff and determined the awareness and use
of language resources available. The second source conducted a study of rural hospitals. Rural
was defined as the hospital not being within any metropolitan statistical area. The final sample
included 841 hospitals. A ten-question survey was mailed to each hospital and asked information
regarding the interpreter services available and the existence of a language assistance policy. The
third source completed an observational study and calculated costs incurred by a group of eight

California hospitals that formed a network of trained interpreters. The fourth source conducted a
survey with internal medicine, family medicine, and generally surgery resident physicians. The
residents were all from one academic medical center, but cared for patients within two separate
hospital systems. One of the hospital systems was public while the other was private, however,
both systems had interpreters on site.
Data Processing and Analysis Procedures
The data presented in these four sources was completely analyzed. Each source was
analyzed for content that related to the four sub-topics presented in Chapter II. A summary of
each source was created. Then trends between each source relating to each sup-topic were
identified. These summaries and trends made it possible to draw conclusions and create
recommendations to answer the research question. In order to create summaries and analyze
trends important information had to be located within the sources and then accurate
interpretation of that data had to be completed. It was also important to ensure that only pertinent
sources were being utilized from credible sources.
Methodological Assumptions
In order to complete this study of preexisting data it was assumed that the data was
collected in an ethical manner. This means that the authors of the studies had permission to
complete the surveys and questionnaires that were part of their study. It was also assumed that
the recipients of the surveys and questionnaires answered honestly and did not provide any

misleading information. The authors then accurately reported this information without skewing
the information in any way or providing any misleading information.
Methodological Limitations
This study is limited to the limitations of the four sources. One of the biggest limitations
is the age of the data. Any study needs to have the most up-to-date information and the older the
information is the less applicable it is to current situations. This study is also limited to the areas
of the sources. This study is not representative of every healthcare organization in the U.S and is
not representative of any other country’s healthcare system. The data is limited to 8 hospitals in
California, 841 rural hospitals, 23 hospitals in Florida, and resident physicians from one medical
academic center. It not representative of every patient demographic present within the U.S.

Chapter IV
Findings
Introduction
This study is a meta-analysis and representative of four sources regarding language
services in healthcare. The data obtained from each source will be summarized and then trends
found within the data will be analyzed. There will be presentations of tables from the sources to
create visual representations of the data collected. This process will find solutions to the research
topics and also allow recommendations to be made.
Effects of disparities in language access on the quality of healthcare
Summary of first article. In the article “Language Services in Hospitals: Discordance in
Availability and Staff Use” (Tschurtz et al., 2011), the authors discuss the many effects of not
using language services when treating LEP patients. Not having proper communication leads to
adverse events, diminished healthcare quality, and low patient satisfaction. English-speaking
patients find it challenging to describe or understand medical problems and treatment plans, but
for a LEP patient is even more challenging and sometimes nearly impossible. This leads to
misunderstandings about diagnoses, treatment plans, medical history, and medication
instructions.
Summary of second article. According to “Rural Hospitals and Spanish-Speaking Patients with
Limited English Proficiency” (Torres et al., 2008), language differences contribute to patient
safety and healthcare concerns for LEP patients. LEP patients visiting emergency rooms will

often receive more diagnostic testing and higher visit times when language services are not
utilized. It has been found that LEP patients are four times more likely to misunderstand
medication labels than English-speaking patients. It was also found that LEP families seeking
healthcare services have been associated with doubling the risk of adverse events during
pediatric hospitalizations.
Summary of third article. The third article “Shared Networks of Interpreter Services, at
Relatively Low Cost, Can Help Providers Serve Patients with Limited English Skills” (Jacobs et
al., 2011), discusses the various effects of not providing language services for LEP patients.
According to the article LEP patient are at risk for reduced access to health services, decreased
satisfaction in care, longer hospital stays, and an increased risk of medical errors and
misdiagnoses. The article also describes the effects of providing professional interpreters as
being increased satisfaction and improved clinical outcomes. However, even though it has been
proven that providing adequate language services to LEP patients equates to better outcomes,
physicians still under utilize professional interpreters during clinical encounters.
Summary of fourth article. The fourth article, “From Admission to Discharge: Patterns of
Interpreter Use among Resident Physicians Caring for Hospitalized Patients with Limited
English Proficiency” (Tang et al., 2014), the authors also list poor control of diabetes in addition
to poor clinical outcomes, longer hospital stays, and increased medical errors and diagnoses as
effects of not utilizing language services when treating LEP patients. The article also notes that
the underuse of language services is growing rather than diminishing.

Trends and themes in the articles. All four articles discuss the adverse effects of not utilizing
language services for LEP patients. The four articles list common effects including extended
hospital stays, misdiagnosis, medical errors, poor understanding of treatment plans including
medications, and poor patient satisfaction. The articles also comment on the adverse effects of
not providing language services when a patient is not in an acute care setting. These can include
not seeking medical attention right away, not receiving preventative services, not adhering to
medication regiments, and not following treatment plans.
Analysis of trends and themes. With so many proven adverse effects of not providing language
services to LEP patients it is imperative to implement changes to increase language services
utilization. Not providing language services not only lowers healthcare quality and patient
outcomes it also opens the hospital and physicians up to legal ramifications. Not properly
completing informed consent alone can result in a battery charge. Disparities in access to
language services are a very large problem that effects the entire healthcare industry. With the
passing of the Affordable Care Act many more citizens will have health insurance and will be
utilizing the healthcare industry more. This means that healthcare organizations need to prepare
themselves for the possibility of more LEP patients requiring language services.
Types of Language Services Available

Summary of first article. “Language Services in Hospitals: Discordance in Availability and
Staff Use” (Tschurtz et al., 2011), discusses the various types of interpretation services available
for use in healthcare. The most obvious resource is a professional interpreter. Professional
interpreters are formally trained to interpret in medical situations. It has been shown that
professional interpreters increase patient satisfaction, decreases miscommunication rates, and
improves access to healthcare for LEP patients. Other language resources include: telephone or
video interpreters and translated documents.
Summary of the second article. “Rural Hospitals and Spanish-Speaking Patients with Limited
English Proficiency” (Torres et al., 2008) also discusses the possible language services available
to healthcare organizations. The study found that the most common language tools used in rural
hospitals were brochures, language identification posters, and language identification cards. The
most commonly used resources for providing oral interpretation was: bilingual employees whose
primary role was not interpretation, telephone interpreters, and friends or family of the patient.
The article also found that the use of informal interpreters, such as family members, resulted in
25 to 50 percent of words and phrases transmitted incorrectly. It was also shown that informal
interpreters may be unfamiliar with medical terminology and tend to summarize information and
insert their own personal bias. This does not allow for the patient to receive accurate information
to make informed medical decisions.
Summary of the third article. The third article, “Shared Networks of Interpreter Services, At
Relatively Low Cost, Can Help Providers Serve Patient with Limited English Skills” (Jacobs et

al., 2011) focuses on the use of professional interpreters to provide language services to LEP
patients. This article brings to light the possibility of healthcare organizations utilizing a shared
remote network of interpreting services. These interpreters were reached via videoconferencing
or telephone. The interpreters are always available to the hospitals and are “on demand”.
Summary of the fourth article. In “From Admission to Discharge: Patterns of Interpreter Use
among Resident Physicians Caring for Hospitalized Patients with Limited English Proficiency”
(Tang et al., 2014) the authors focus on the use of professional interpreters. The two hospitals
where the resident physicians worked, professional interpreters were available for use. The
public hospital had 25 professional interpreters for 12 different languages, seven days a week
during daytime hours. The private hospital had four professional interpreters for three different
languages, seven days a week during daytime hours. Both hospitals also provided telephone
interpreters 24 hours a day.
Trends and themes in the articles. All four articles describe very similar resources for language
services. The most common was professional interpreters, via in-person, telephone, or
videoconferencing. The use of translated documents, brochures, language identification cards,
and language identification posters. One study was based on a network of hospitals utilizing the
same remote interpreters to help reduce cost and ensure access to language services for their LEP
patients. It was also noted that use of informal interpreters was not a substitute for professional
interpreters. Informal interpreters are not recommended for many reasons, no matter how
convenient they are for medical staff.

Analysis of trends and themes. There are many resources available for healthcare organizations
to provide language services to their LEP patients. Some of these include translated documents
or brochures. However, the most successful forms of interpreting services come from
professional interpreters. Professional interpreters are available in person, over the telephone, or
by video conferencing. By providing these services the risk of miscommunication and other
adverse events decreases. It is also necessary for healthcare professionals to understand the risks
of using informal interpreters. Using family members or friends is not an acceptable for of
interpretation for many reasons, and should be discouraged. Healthcare organizations need to
educate their employees on the importance of utilizing appropriate language services.
Why Language Services Are Not Utilized
Summary of first article. In “Language Services in Hospitals: Discordance in Availability and
Staff Use” (Tschurtz et al., 2011), the authors discuss some reasons that language services are
not available or are available but not utilized by staff. Many staff members are not trained to
work with professional interpreters or receive little to no education on why utilizing language
services is important. The authors discovered that a discordance existed between what language
services hospitals said they provided and what services staff reported using. Many staff were not
aware of the services available and those who were aware did not use them or used them
infrequently. Some reasons listed for not using the services included: interpreters not being
readily available, equipment such as telephones being inaccessible, or staff not knowing how to
access these services.

Summary of second article. In “Rural Hospitals and Spanish-Speaking Patients with Limited
English Proficiency” (Torres et al., 2008), lack of funding for interpreters, lack of local language
training programs, and lack of state agency support are listed as the main reasons for not utilizing
or providing interpreter services. The article also adds that rural hospitals having fewer language
resources than urban hospitals. In order to provided interpreter services in all healthcare
encounters it was estimated that it would cost $268 annually which would increase the national
healthcare expenditures by 0.5 percent. However, this analysis does not include the potential
savings from decreasing medical errors and improving efficiency of care for LEP patients.
Summary of third article. The article “Shared Networks of Interpreter Services, at Relatively
Low Cost, Can Help Providers Serve Patients with Limited English Skills” (Jacobs et al., 2011),
focuses on the cost of providing language services as the main reason healthcare organizations
do not provide adequate language services. The article discussed that using employees as forms
of interpreters actually costs the organization in the form of staff time lost, rather than saving
money. The authors also discussed that using language services actually saves organizations
money by reducing the cost of care provided during emergency room visits.
Summary of fourth article. In “From Admission to Discharge: Patterns of Interpreter Use
among Resident Physicians Caring for Hospitalized Patients with Limited English Proficiency”
(Tang et al., 2014), resident physicians were surveyed regarding their use of language services.
Resident physicians reported using their own limited language skills or ad hoc interpreters to get

by due to time constraints. This occurred more often during pre-rounds, team rounds or check-ins
than during procedural consents or family meetings. Some residents reported not speaking to the
patient at all when they were hurried during rounds. Another reason for not utilizing language
services during rounds is because residents often round early, before interpreters arrive to the
hospital. The authors add that the use of interpreters varied widely and was based on the
resident’s perceived need of language services, rather than the patient’s need of language
services.
Trends and themes in articles. Each article describes various reasons for not utilizing language
services during encounters with LEP patients. Lack of funding, time constraints, lack of
interpreting services, lack of staff awareness are the main reasons for not utilizing language
services. All of the articles discussed the importance of utilizing language services and that most
medical staff also acknowledges the severe consequences that can arise from not using language
services. Even though the staff acknowledges these consequences there are still disparities in
language services access and use.
Analysis of trends and themes. Identifying the reasons behind under-utilization of language
services is important. This is because without knowing why language services are not being
used, healthcare organizations cannot fix the problem. When looking at the most common
reasons given for not utilizing language services, such as staff awareness, it is apparent that those
are all reasons that can be remedied. Because many healthcare organizations are experiencing the

same reasoning behind the under-utilization of language services these reasons are most likely
not isolated to a single hospital, but rather the healthcare industry as a whole.
Recommendations to Improve Language Services
Summary of first article. In “Language Services in Hospitals: Discordance in Availability and
Staff Use” (Tschurtz et al., 2011), the authors discuss increasing staff awareness of language
services available to them, as many staff reported being unaware of these services. Also
increasing staff awareness of the importance of not using ad hoc interpreters would lead to using
appropriate language services. The authors also discuss the importance of assessing the
competency of using bilingual staff as healthcare interpreters. Professional healthcare
interpreters have to go through training that not only involves language skills, but medical
terminology and healthcare ethics. Professional interpreters must also pass assessments and
exams. Using staff as interpreters is not ideal because they have not been formally trained. The
authors also stress the importance of assessing population data in order to plan and evaluate
language services available within the organization.
Summary of second article. The authors in “Rural Hospitals and Spanish-Speaking Patients
with Limited English Proficiency” (Torres et al., 2008), discuss various ways to improve
language access disparities in healthcare organizations. The first is to look at the business side of
providing language services. While providing language services does cost money, it also saves
money in the long run, and reduces risk incurred by the healthcare organization. Having written
policies that are used educate staff, not only during orientation, but also continually throughout

employment. Having trained interpreting staff, rather than just bilingual staff, and having trained
interpreters at all hours, not just during business hours. Finally, forming partnership between
organizations. Especially in rural areas where resources are not as abundant as in urban areas.
Summary of third article. The authors of “Shared Networks of Interpreter Services, at
Relatively Low Cost, Can Help Providers Serve Patient With Limited English Skills” (Jacobs et
al., 2011), described in detail the use of a shared network of interpreters between healthcare
organizations. Because there is a limited amount of professional interpreters available for hire, it
makes sense to create a network of interpreters to serve various healthcare organizations. This
helps to reduce the cost to the hospital, and allows for more hospitals to have access to
professional interpreters. The system not only for immediate videoconferencing in most cases,
but also automatically turns to telephone conferencing if an interpreter is not immediately
available via video.
Summary of the fourth article. The fourth article, “From Admission to Discharge: Patterns of
Interpreter Use among Resident Physicians Caring for Hospitalized Patients with Limited
English Proficiency” (Tang et al., 2014), the authors focus on the importance of improving
residents’ use of professional interpreters routinely. Including the daily use of interpreters as a
quality improvement goal and performance dashboard was suggested. The authors also suggest
setting a minimum standard for daily interpreter use, especially in urban areas, could help
improve the rate of language services utilization. The authors acknowledge that many resident
make their first rounds very early, before interpreters arrive. To address this issue, add an

interpreter to each team while rounding or implement a system to alert interpreters when a LEP
patient is admitted and will be needing their services.
Trends and themes. Each article suggests many solutions that would lower disparities in
language access. Educating staff was one of the most important solutions. Discovering cost
effective solutions to increase language services was also suggested. Utilizing and sharing
interpreters in cost effective ways, rather than incurring the costs of medical error due to poor
patient-provider communication. Also, recognizing that providing language services will lead to
cost savings in the long run.
Analysis of trends and themes. By analyzing current language service access in a healthcare
organization, administrators will be able to determine what improvements need to be made.
Improving language services will not only save the organization money, but also improve the
community surrounding the organization. Providing adequate language services will encourage
more LEP patients to utilize the healthcare industry and have better health outcomes and
experiences within the industry.
Data Analysis Conclusion
The data has proven that disparities in language services are a real concern that can lead
to severe consequences. Not providing adequate language services to LEP patients can lead to
adverse events, dissatisfaction, and under-utilization of the healthcare industry. While there are

many different reasons that lead to disparities in language services access, there are solutions to
the problem that can be implemented to eliminate disparities.

Chapter V
Summary, Conclusion, Recommendations
Summary
The data in Chapter IV demonstrates the various consequences that result from not
utilizing language services during encounters with LEP patients. LEP patients are at a higher risk
for adverse events when seeking medical care if they are not provided with language services.
Adverse events could include misdiagnoses, undiagnosed issues, serious complications resulting
from medication error or not understanding physician instructions, and more diagnostic testing
than is necessary. LEP patients also have higher rates of dissatisfaction with their healthcare.
With higher dissatisfaction, LEP patients are less likely to seek medical attention, in emergent or
preventative settings.
Even though they may not be utilized, there are many language services available. With
the advancement in technology, patients do not need to have a professional interpreter in the
room with them. Interpreters can be off-site with the use of telephone or videoconferencing.
Videoconferencing is especially useful for deaf patients who require sign language. There are
also language services available as applications on tablets or telephones to assist patients with
communicating with their healthcare providers. Having translated documents that are commonly
used, such as informed consent, readily available is also important. Utilizing family or friends of
the patient as informal interpreters is not an acceptable form of translation, and is discouraged.
Using family and friends as an interpreter is an easy option that many healthcare
professional use because it saves time rather than using proper interpretation services. It is also
probable that providers are not well educated on the language services available to them. Many

healthcare organization lack proper funding for language services, or may not have access to
professional interpreters in rural areas. These are all reason given for not utilizing language
services when treating LEP patients. However, these reasons are not excusable, especially when
a patient’s life could be in danger.
Finding solutions to these reasons is extremely important to all healthcare organizations.
With the rise in citizens procuring health insurance there will also be a rise in the rates of
utilizing the healthcare industry, and organizations need to be able to provide acceptable care to
LEP patients. Educating providers, allocating more funds for language services, and better
utilizing professional interpreters are all ways to decrease disparities in access to language
services.
Conclusion
In conclusion, the data presented in Chapters II and IV demonstrates the need to improve
language access within the healthcare industry. “In the United States, limited-English-proficient
patients experience healthcare disparities, including reduced likelihood of physician and mental
health provider visits, lower incidence of mammograms and influenza vaccinations, and
increased risk of patient safety events” (VanderWielen et al., 2014, p. 1324). The costs of poor
communication between physicians and patients are higher than the cost of providing language
services to LEP patients.
Being provided adequate language services while receiving care is a right afforded to all
persons by the Civil Rights Act. It is also mandated by Federal laws, many states require it, and
many accreditation agencies also require adequate language services. The ACA reinforces the

right to language services for LEP patients. “The ACA treats language access as a foundational
element of high quality healthcare” (Teitelbaum et al., 2012, p. 372). In order to comply with
laws, decrease the risk of adverse events, increase satisfaction, and quality of care for LEP
patients, it is imperative that healthcare organizations evaluate their current language services
departments and make steps to improve it. “Providing interpretation and translation services to
LEP patients is an important step in eliminating healthcare barriers and providing effective
healthcare” (Coren et al., 2009, p. 638)
Recommendations
It is recommended that all healthcare organizations make it a priority to evaluate their
current language services department. In order to improve language services within their
organization implementing strong written policies to educate staff on the importance of
providing appropriate language services to LEP patients. The policies need to also include the
types of resources available to staff and how to access those resources. These policies not only
need to be presented during initial orientation but no less than annually. These policies need to
be directed to all staff providing direct care including physicians and nurses. Policies should also
include the risks of using ad hoc interpreters, even though it is a convenient option.
A lack of professional interpreters is something that also needs to be addressed. This
could be an area that additional data would be needed. Creating and promoting programs to
provide education and a career to individuals who have an interest in interpreting would be
beneficial. It is also necessary to utilize the available professional interprets efficiently. Creating

a network of interpreters paid for by a group of healthcare organizations is a way to efficiently
uses available interpreters and reduce costs to organizations.
Creating better systems of identifying LEP patients and alerting language services staff to
their existence would also be beneficial. If interpreters do not know that patients need their
services, than they cannot provide them. An electronic tracking system would be ideal, especially
with the introduction of electronic medical records in many healthcare organizations. Providing
language services during physician rounds is also needed. Providing language services in
primary care and specialty care offices is also needed. This will help to ensure LEP patients are
properly diagnosed and are able to understand their treatment plans, which will ultimately
reducing emergency room visits.
More data on medical staff utilizing language services in various settings would be useful
to continue this research. Most of this research is based in an acute-care setting of a hospital, but
there is no data on the use of language services during emergency situations outside of the
hospital. This could include situations such as vehicle accidents or medical events within a
patient’s home. More research needs to be conducted on first responders or emergency
dispatchers providing language services to LEP patients. Although there are many language
resources available, there is still a long way to go in ensuring these resources are properly
utilized. With the increasing rates of insured patients and rising healthcare costs, it is imperative
that access to language services also increases.

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