Standard 4: Qualified Language Assistance Services (mandate)

“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.”

It is important to note that Standards 4, 5, 6, and 7 concern provisions of Title VI of the Civil Rights Act of 1964 (Title VI), which requires all entities receiving Federal financial assistance, including healthcare organizations, take steps to ensure that individuals with limited English proficiency (LEP) have meaningful access to their services. For a more detailed discussion, please see: Providing Health Care to Limited English Proficient Patients. [Mateo J, Jr, Gallardo EV, Huang VY, Niski C, for the California Primary Care Association. Providing Health Care to Limited English Proficient Patients: A Manual of Promising Practices. California Primary Care Association; Sacramento, California.

Language services must be made available to each LEP person who seeks services, regardless of the size of that person’s language group in that community, so that she or he can interact effectively with appropriate staff. These provisions also apply to patients needing American Sign Language services.

Having available bilingual staff who can communicate directly with patients in their preferred language is the first preference. If that is not possible, face-to-face interpretation by trained staff or contract or volunteer interpreters is the next preference. Healthcare organizations should turn to telephone interpreter services only when an interpreter is needed instantly or services are needed in an infrequently encountered language.

Both formal studies and anecdotal accounts have established that language barriers can limit the ability of an LEP person to get the full benefit of healthcare services. Moreover, research has demonstrated that patients are more satisfied and adhere better to recommended treatments when language assistance is provided. The Office for Civil Rights (OCR) guidance on persons with LEP has also established the civil rights case for providing such services.

Language assistance strategies and model programs
Healthcare organizations employ many different approaches to overcome language barriers between staff and patients: bilingual providers, bilingual/bicultural community health workers, and interpreters (onsite and telephone). Some approaches may be most suitable for only specific types of healthcare settings, and others may be useful in almost any setting.

One recent overview of possible approaches, Language Access: Understanding the Barriers and Challenges in Primary Care Settings, is available from the Association of Clinicians for the Underserved. [Barrett SE, Dyer C, Westpheling K., Language Access: Understanding the Barriers and Challenges in Primary Care Settings. Association of Clinicians for the Underserved; McLean, Virginia; 2008. Available at:] A wide selection of other language publications and tools is also available from Diversity RX, a nonprofit project of the Tides Center.

Many healthcare professionals are concerned about the challenges and costs of providing linguistic services, but programs currently in use at community health centers, health departments, hospitals, and managed care organizations can serve as models for other programs.

Used with permission from the National Center for Cultural Competence

Linguistic competence is the capacity of an organization and its staff to communicate effectively and to convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are hearing-impaired. Linguistic competency requires organizational and provider capacity to respond effectively to the health and mental-health literacy needs of populations served. The organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity.—Goode & Jones. National Center for Cultural Competence, Georgetown University Center for Child & Human Development.

Smaller facilities. Smaller healthcare organizations—eg, community health centers and health departments—most often rely on bilingual employees and staff or volunteer interpreters who may also have other job duties. Some smaller facilities use or operate community interpreter services, which have the advantage of providing expertise in different languages. Essentially, these are shared resources that allow many providers to access contract interpreters, especially from small language groups. Advantages of community services include their ability to provide in-person, local ethnic expertise at affordable cost and interpreters who are trained specifically for medical settings. Following is a small selection of these types of programs from around the country:

Larger facilities. Healthcare networks and multifacility managed care organization—with their large numbers of providers and ethnically diverse patient populations—can face some of the greatest challenges in providing language services. The language programs developed at the following 2 large networks suggest some of the ways that larger organizations can provide appropriate language services in challenging settings:

  • Alameda Alliance for Health—a public, nonprofit managed care plan serving lower-income individuals in Alameda County, California—provides several onsite and on-call options for interpreter services for its enrolled patients.
  • Kaiser Permanente, in its various service areas across the United States, offers bilingual health professionals at facilities where demand is greatest and has access to telephone interpreters of more than 140 languages—in addition to American Sign Language interpreters, assisted listening devices, and large-print materials.

With varying approaches like the ones suggested above, most healthcare organizations should be able to develop a flexible combination of programs that can meet the language needs of the patient populations that they serve. Such a combination could include:

  • A roster of bilingual providers
  • In-house or contract interpreters
  • Bilingual/bicultural case managers to handle nonclinical encounters such as member services calls or health education visits
  • Networking agreements with hospitals and other larger facilities that have onsite language services

Independent contract pharmacies, laboratories, and diagnostic facilities facing the challenges of not having their own language services may be able to use the telephone interpreter services of the institutions with which they are contracted.





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