Standard 6: Ensuring Qualified Bilingual and Interpreter Services (mandate)
“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
When language barriers occur in healthcare
settings, relying on staff who are not fully bilingual or lack interpreter training can lead to misunderstanding, dissatisfaction, omission of vital information, misdiagnoses, inappropriate treatment, and lack of adherence. Providers cannot simply use any bilingual person; rather, they must assess and ensure the competency of individuals providing such services.
Bilingual staff members who communicate directly with patients must demonstrate a command of both English and the target language, including facility with the relevant terms and concepts. When possible, formal testing should confirm competency. Many individuals who have learned a second language overestimate their ability to communicate in that language and make errors that could result in miscommunication. The National Council on Interpreting in Health Care (www.ncihc.org) recommends at least 40 hours of formal training in the techniques, ethics, and cross-cultural issues involved in medical interpreting, including the interpreters’ ability to convey information accurately in both languages.
Because of the need for accurate, impartial, and confidential communication, family members or friends should not act as interpreters. However, a patient may choose to use a family member or friend as interpreter after being informed of the availability of free interpreter services—unless that would compromise the effectiveness of services or violate the patient’s confidentiality. Documentation of the use of a trained interpreter, or offer of that service, should be entered into the patient’s record.
Qualified vs Unqualified Interpretation
Among healthcare providers, understanding varies about what constitutes competence in medical interpretation. Some may equate “professional” simply with “paid.” However, not all “trained” or “certified” interpreters are trained or certified in the specific skills and ethics required in medical interpretation. Locating and using only qualified interpreters is critical.
Interpreter Role, Skills Assessment, and Certification
To assure quality interpreter services, healthcare organizations need to have clear, accepted definitions of roles, training, and competency. Staff members who work with interpreters need to understand what interpreters do and do not do and who is responsible for different aspects of communication. For guidance, the National Council on Interpretation in Health Care (NCIHC) has published the “National Standards of Practice for Interpreters in Health Care.” [National Council on Interpretation in Health Care. The National Standards of Practice for Interpreters in Health Care. Washington, DC; September 2005. Available at: www.ncihc.org/mc/page.do?sitePageId=57768&orgId=ncihc.]
With limited numbers of formally trained medical interpreters, healthcare organizations may pay insufficient attention to the skills and competency of any particular individual who is called on to interpret. Consequently, individual organizations typically use their own assessment tools in hiring interpreters. Therefore, developing standard tools for assessing basic medical interpreter skills is key to preparing certification requirements for interpreters, and this is among the efforts being pursued by the NCIHC.
Medical Interpreter Training
In the absence of standardized interpreter skills assessments, some healthcare institutions conduct assessment and training in-house; others work with programs at local colleges or community organizations. When qualified trainers are not available locally, it can be beneficial for several institutions to collaborative in establishing a local or regional training program based on one of the existing training models. This collaborative structure can be expanded to house a community-based pool of interpreters who could be shared among provider organizations. Essential training topics include:
- Instruction in interpretation skills and techniques
- Ethics of interpreting in healthcare encounters
- Review of key medical terminology, basic clinical concepts, and the workings of the US medical system
- Overview of the role of culture and how to manage cultural issues
Bilingual individuals, unless trained as health professionals in another country, typically have conversational skills only in the target language, and would need to learn medical terminology through a course of study. There are similar concerns with bilingual staff or health professionals who communicate directly with LEP patients. Although these staff members might have learned a language conversationally at home or during their education, they may lack training in medical terminology and concepts. Although lists of untested bilingual staff who have served for both direct patient care and interpreting are available from healthcare organizations in some areas, these lists may not reflect the realities of available language access, as the individuals on them may not always be available or qualified to act in a bilingual or interpreter capacity.
Some organizations use courses like “survival Spanish” or other intensive language courses to prepare for dealing with the increasing numbers of LEP patients. Such courses may improve basic communication with LEP individuals, but they risk leading clinicians to believe that they can adequately communicate during complex clinical encounters. A study conducted at Stanford University found that medical residents who took a 45-hour course in medical Spanish still made a considerable number of mistakes in communicating with patients who spoke only Spanish. [Prince D, Nelson M. Teaching Spanish to emergency medicine residents. Acad Emerg Med. 1995;(1):32-36.] A study by Haffner reported many instances of physicians who believed they had a sufficient command of a language but, in fact, understood their patients incorrectly or made replies that were confusing, incorrect, or insulting. [Haffner L. Translation is not enough. Interpreting in a medical setting. West J Med. 1992;(3):255-259.]
Family and Friends as Interpreters
Standard 6 does not mean to exclude family or friends from healthcare encounters; indeed, when patients wish, family or others should be involved in healthcare decisions. Moreover, family and friends may be able to be more involved in patient care if they do not also need to do the interpretation. It is important to stress to patients who have brought their own interpreter that a trained staff interpreter will be provided and that if they still want to use their own interpreter, the staff interpreter will remain present to ensure that both the patient and the clinician are receiving accurate information.