Health Reform WK-EDGE Translation of vital medical documents essential for LEP care
Monday, September 19, 2016

Translation of vital medical documents essential for LEP care

By Sarah E. Baumann, J.D.

The proper translation of vital medical documents improves patient care and averts misunderstandings that can have diremedical and legal consequences. In a Health Care Compliance Association Webinar titled, "Translating Vital MedicalDocuments for your Limited English Proficient Patients," Jill A. Mead, Esq., In-House Compliance Counsel for Vocalink Language Services, provided an overview of legal requirements for the translation of medical documents, strategies for selecting documents and languages for translation, and tips for effective translation.

Title VI of the Civil Rights Act of 1964 prevents discrimination based on national origin. Section 1557 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), and a related Final rule (81 FR 31376, May 18, 2016) proscribed such discrimination in the health care arena (see Final rule eyes equity and an end to discrimination in healthcare, May 18, 2016). Failure to provide limited English proficient (LEP) patients with necessary documentation in a language they can understand can be considered discrimination.

Vital medical documents. Mead offered four factors to consider when determining which medical documents are considered so vital that they must be translated:

  1. the number of proportion of LEP patients likely to use the document;

  2. the frequency with which LEP patients will see the document;

  3. the nature and importance of the document to patients; and

  4. the resources available and costs to the entity.

She warned, however, that courts will almost never consider costs to the entity to be a valid consideration in failing to translate a document, and thus stated that providers should only consider the first three factors. Certain documents with significant clinical and legal consequences, such as those identified by The Joint Commission (TJC)—informed consents, complaint forms, free language service information, notices of eligibility and rights, and intake forms with clinical consequences—will almost always be considered vital.

Informed consent forms are probably the biggest source of litigation related to improper or non-existent translation. Mead described a situation in which a patient died a during kidney removal procedure. The underlying facts demonstrated that the hospital was not sure which language she spoke with fluency—Amharic, a language spoken in Ethiopia, or Arabic—and that she was presented with, and signed, an informed consent agreement written in English that did not mention potential kidney removal as a possibility. Furthermore, no qualified interpreter explained the risks of surgery to her in her native language. The hospital settled the case with her family for $85,000, plus $10,870 in legal fees.

Informed consent forms are formatted differently among providers, which can cause additional difficulties. For example, in describing a translated form that described the "nature of the operation or procedure" as "insert description here," Mead asked, "Can your staff write in Mandarin Chinese?"

Mead added discharge instructions and menus to TJC’s list of vital medical documents. Misunderstood discharge instructions can lead to safety issues if patients do not follow them as appropriate. In addition, they can lead to hospitals admissions within 30 days of discharge, resulting in penalties to the hospital. TJC does not consider menus to be vitalmedical documents, but Mead disagreed, noting that patients use them with great frequency and that they have potentially significant clinical and legal consequences. For example, LEP patients on restricted diets may not be able to identify low-salt or low-fat options. In addition, hospitals may face lawsuits from patients whose religions forbids the consumption of certain foods if patients are unknowingly served those foods due to translation issues.

Choosing languages for translation. In its Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Original Discrimination Affecting Limited English Proficient Persons, HHS offered a safe harbor to providers that offer translated documents according to a specific formula. Providers must determine which languages are spoken among the population they serve. They must then calculate 5 percent of that population. If a language is spoken by the lesser of 5 percent of the population or 1,000 individuals, the hospital must translate all languages greater than that number. For example, a hospital system that serves 1 million patients per year would calculate 5 percent of its population to be 50,000. One thousand is less than 50,000. Therefore, the system would be required to translate documents to all languages spoken by more than 1,000 patients. If the figure is close, however—for example, if one language is spoken by 960 patients—Mead suggests translating, anyway.

Translation tips. Mead stated unequivocally to never use machine translation. She provided examples of errors in Google Translate that ranged from the merely confusing—translating "Your wife is stable" to "Your wife cannot fall over"—to the dangerously misleading—translating "Your child’s condition is life threatening" to "Your child’s state is not life stopping."

Providers must ensure that translators are qualified. Unqualified translators may not understand or be able to translate specialized medical terms. They may also be tripped up by false cognates—words from different language that sound alike, but have different meanings—such as the Spanish "embarazada," which means "pregnant," rather than embarrassed.

Forms work best when questions are not open-ended. For example, it is best to ask patients to choose from a checklist to describe their pain—burning, stabbing, etc.—rather than ask them to simply describe their pain. Descriptions may include extraneous information, and may not provide medical professionals with the information they need to assist patients. In addition, open-ended questions may allow individuals to use colloquial terms unfamiliar to the translator.

Interpreters, who perform verbal translations, have different skillsets than translators, who translate written text; neither should perform the other’s job. Interpreters should never be asked to do "sight translation"—glancing at a document and verbally translating. However, interpreters should be brought in to explain translated documents after a patient has reviewed them. All patients have questions, and medical professional frequently answer questions from native English-speakers about documentation or procedures. LEP patients should be given the same opportunity. When translated documents are not available, providers should use a qualified interpreter to explain an English document, have the patient sign it, and carefully detail in the record what was explained, how the provider verified patient understanding (for example, through a question-and-answer session or through teachback), and the identity of the interpreter.

Wayfaring and signage. Mead also discussed the use of signage and wayfaring—visible, audible, tactile elements strategically placed throughout organization to facilitate navigation. She recommended that such elements should be posted at initial patient points of contact; key departments, such as the emergency room; frequently used areas, including the cafeteria; and emergency evacuation routes. Where possible, symbols can be used to aid in understanding. For example, the cardiology department and signs leading to it may be labeled with a heart, in addition to words.

Companies: Vocalink Language Services

IndustryNews: NewsStory NewsFeed AccessNews AgencyNews GeneralNews HospitalReadmissionNews QualityNews

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