Complying with language access requirements is a risk management tool and a quality of care issue for providers communicating with patients and caregivers who are deaf, hard-of-hearing, or have limited English proficiency (LEP). In a Health Care Compliance Association (HCCA) webinar titled "Improving Limited English Proficient Patient Compliance," Jill A. Mead, Compliance Counsel, Vocalink Language Services, spoke about compliance requirements and offered tips to overcome language and cultural barriers. Mead attributed failure to comply with language access requirements as a leading cause of patient noncompliance—that is, failure to follow a doctor’s orders—which costs 125,000 deaths per year in the United States and hundreds of billions of dollars in emergency department trips and hospitalizations.
Language access compliance. Providers must comply with statutes, including the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), regulations, executive orders, and accreditation standards regarding language access for LEP individuals. This is a general compliance issue, but also one of risk management—avoiding claims and lawsuits alleging medical malpractice or discrimination—and quality of care. Patient noncompliance, which includes medication errors like failure to fill or take all recommended doses of a prescription, not following diet or exercise plans or quitting physical therapy, or being late or skipping appointments, can prevent a provider from effectively preventing and treating illness and injury, and can lead to avoidable readmissions, which can lead to penalties under the ACA’s readmission reduction program. Mead discussed two types of barriers that providers must overcome: language barriers and cultural barriers.
Overcoming language barriers. Incorrect or incomplete translations lead to many problems for providers. Mead gave the example of having a discussion with a patient in-office regarding requirements before an upcoming appointment, but then handing the patient a boilerplate document of the same requirements in a language the patient does not fully understand. Medical translation is a very specific skill beyond that of most lay persons, despite fluency. The wording of prescriptions can also lead to problems—Mead cited a case study where the medication bottle instructed the patient to take the medication "once" a day, meaning one time. However, the LEP patient spoke Spanish, and read "once" as 11 times, leading to an overdose. Another problem is false cognates, or words in one language that sound similar enough to a word in another language that speakers assume they have the same or a similar meaning, but have two different discrete meanings. Mead called the Spanish word "intoxicado" the "most famous false cognate in compliance" because in 1980, it led to serious permanent injuries to an 18-year-old patient. The man’s Spanish-speaking family said that he was "intoxicado," meaning nauseated and possibly suffering from food poisoning; the health team interpreted that to mean he was "intoxicated," and treated him for drug overdose. The mistranslation ignored his actual symptoms of dizziness, headache, and nausea, which were caused by an intracerebellar hemorrhage. The patient ended up a quadriplegic, and settled his malpractice settlement against the hospital for $71 million.
To overcome these barriers, Mead recommends patient education about the severity of the condition, importance of treatment, and risks associated with foregoing treatment. Providers should use pre-appointment reminder phone calls, from an actual person, using interpreting staff to decrease no-shows. Voicemail messages may be left with patient consent, which should be noted in the patient’s medical records, and messages should include contact name and phone number. Mead recommended using multilingual online resources, written materials, and follow-up calls, along with the use of professional interpreters.
Overcoming cultural barriers. Cultural barriers include patient beliefs about causes of illnesses, methods of treatment, communications with physicians, and the timing of appointments. Mead spoke about the differences between egalitarian and hierarchical cultures, noting that patients from a hierarchical culture may afford a physician high respect due to their status and refuse to question that physician’s orders. There may also be cultural issues regarding decisionmakers and caregivers depending on their relative status to the patient. Other cultural differences include the ways individuals express their level of pain; expressive patients communicate pain with extreme levels of yelling or screaming, while stoic cultures expect individuals to bear pain without crying or to refuse the first offer of pain medication out of politeness. Some cultures require familial involvement in decisionmaking, though which family member is highly dependent on the specific cultural norms. Provider communications should also be aware of cultural differences, such as eye contact or whether the patient prefers a collaborative or directive approach to treatment.
Mead suggests three main steps for physicians when working with patients from unfamiliar cultures:
- Ask: "Is there anything we need to know or can do to support you?"
- Listen: Listen with caring and curiosity, with non-judgmental and non-assumptive ears. Pay close attention to non-verbal communications.
- Follow through: Make resources available, do what you promise, seek exceptions to rules where appropriate.
She referred to the "four C’s of culture"—call (ask the patient about his or her perception of symptoms, what he or she calls the problem); cause (ask the patient what he or she believes is the cause of the problem, not discounting the effects of mental beliefs); cope (ask the patient what he or she has done to try to relieve symptoms and what other treatment they have sought); and concerns (ask the patient about his or her concerns, how he or she perceives the severity of the condition, and what complications he or she is afraid of).
Mead noted that special care should be taken with patients who have sought alternative or non-Western medical attention. If the traditional remedies in the patient’s culture are not harmful, the provider should maintain respect for those remedies, try to include the traditional remedies with medical remedies, explain the differences in how each works, and monitor compliance. If, however, the traditional remedies conflict with medical remedies, the provider needs to be aware of them and explain the conflict and related dangers to the patient while trying to incorporate elements of the traditional remedy into treatment if possible.
Companies: Health Care Compliance Association; Vocalink Language Services
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