Quick Safety 13: Overcoming the challenges of providing care to limited English proficient patients

Updated: October 2021

Issue:

There is a large and growing population of people in the United States with limited English proficiency (LEP), which presents challenges to health care organizations providing care to patients and their families with LEP.

Based on analysis of recent Census Bureau data for 2018, the Center for Immigration Studies found that 67.3 million residents in the U.S. now speak a language other than English at home, a number equal to the entire population of France. The number has nearly tripled since 1980, and more than doubled since 1990. The growth at the state level is even more pronounced. The states with the largest share of their populations speaking a foreign language at home in 2018 were California (45%), Texas (36%), New Mexico (34%), New Jersey (32%), New York and Nevada (each 31%), Florida (30%), Arizona and Hawaii (each 28%), and Massachusetts (24%).¹

LEP patients are at a higher risk for adverse events than English-proficient patients. Language barriers significantly impact safe and effective health care.

When compared to English-proficient patients, LEP patients have:²

• Longer hospital stays when professional interpreters were not used at admissions and/or discharge.
• Greater risk of surgical infections, falls, and pressure ulcers.
• Greater risk of surgical delays due to difficulty understanding instructions, including how to prepare for a procedure.
• Greater chance of readmissions for certain chronic conditions due to difficulty understanding how to manage their conditions and take their medications, as well as which symptoms should prompt a return to care or when to follow up.

Typical challenges that may affect care of to LEP patients in your organization include:

• Use of family members, friends, or nonqualified staff as interpreters
• Provider use of basic language skills to “get by.”
• Cultural beliefs and traditions that affect care delivery, such as expression of pain, respecting authority, gender roles, and class biases.

Because communication is a cornerstone of patient safety and quality care, every patient has the right to receive information in a manner he or she understands. Effective communication allows patients to participate more fully in their care. When a patient understands what is being said about his or her care, treatment, and services, that patient is more likely to fulfill critical health care responsibilities. Communicating effectively with patients is also critical to the informed consent process, helping practitioners and health care organizations give the best possible care. For communication to be effective, the information provided must be complete, accurate, timely, unambiguous, and understood by the patient.

There are laws, regulations, and a body of literature that are relevant to the use of interpreters. These include Title VI of the Civil Rights Act, 1964; Executive Order 13166; policy guidance from the Office of Civil Rights regarding compliance with Title VI, 2004; Title III of the Americans with Disabilities Act, 1990; state laws (many states have laws and regulations that require the provision of language assistance); and the American Medical Association Office Guide to Limited English Proficiency (LEP) Patient Care.

Safety Actions to Consider:

The Agency for Healthcare Research and Quality (AHRQ) offers some systems and strategies³ to facilitate communication among hospitals and LEP patients, including:

• Foster a supportive culture for safety of diverse patient populations.
• Adapt current systems to better identify medical errors among patients with LEP.
• Improve reporting of medical errors (including sentinel events and near misses).
• Routinely monitor patient safety in LEP patients.
• Address root causes to prevent medical errors among LEP patients.

In addition, the following strategies have been successfully implemented to better involve LEP patients in their care:

Integrate professional, dedicated interpreters into the care team:

Increase the visibility of interpreters through proper introductions and include the interpreter in the huddle that occurs prior to entering the patient’s room. Determine the role the interpreter with the patient; the interpreter can be a neutral conduit of information or can also act as an additional patient advocate to help bridge cultural and emotional aspects of care. Clarify the interpreter’s role during training.⁴

Integrate telephone and video interpretation into the everyday workflow:

Consistent use of telephone and video interpretation can help build rapport with the patient and family or advocate, even for small interactions.⁴

Promote the use of patient portals:

One exploratory study found that safety net patients are using the Internet and digital tools but are not aware of their health system’s patient portal. Another finding was that LEP patients feel empowered using a patient portal, because it enables them to manage their own health. You may need to revise your portal content for LEP patients to include the roles of caretaker and family members as a way to encourage patients to use the portal. Highlight the technological help and resources available in the community and provide portal education.⁵

Use of family-centered rounds:

While the use of the patient’s family members and friends as interpreters is discouraged, it has been found that involving the family or advocate in the patient’s care is beneficial.⁴ The American Academy of Pediatrics (AAP) recommends conducting “family-centered” rounds in patients’ rooms with nursing and family in order to share “complete, honest, and unbiased information with patients and their families on an ongoing basis and in ways they find useful and affirming, so that they may effectively participate in care and decision-making to the level they choose.”⁶ Family-centered rounds with multidisciplinary teams improve family involvement and understanding of medical plans, team communication, length of stay, patient safety, and medical education.⁷ In addition to interpreting the communications between the patient and family and the care team, interpret any side conversations that take place in the patient room among the clinical staff; these “sidebar” conversations are sometimes critical to conveying fuller information to the patient and their family or advocate.⁴

Furthermore, organizations can support staff as they work to provide care to the increasing population of LEP patients by:

• Creating a standardized and centralized process to schedule interpreters to ensure coverage.⁴
• Providing dual language materials that staff can share with patients.⁸
• Increasing the number of trained bilingual nursing staff.
• Offering free language lessons to unit staff.⁸

Resources:

1. Zeigler K and Camarota SA. 67.3 Million in the United States Spoke a Foreign Language at Home in 2018. Census Bureau. Center for Immigration Studies. Oct. 29, 2019.
2. Betancourt JR, Tan-McGrory.Creating a safe, high-quality healthcare system for all: Meeting the needs of limited English proficient populations; Comment on ‘Patient safety and healthcare quality: The case for language access. International Journal of Health Policy and Management. 2014;2(2):91-94.
3. Agency for Healthcare Research and Quality.Improving patient safety systems for patients with limited English proficiency: A guide for hospitals.
4. Cheng JH, Wang C, Jhaveri V, et al. Health Care Provider Practices and Perceptions During Family-Centered Rounds With Limited English-Proficient Families. Academic Pediatrics. January 2021.
5. Casillas A, Perez-Aguilar G, Abhat A, et al. Su salud a la mano (your health at hand): Patient perceptions about a bilingual patient portal in the Los Angeles safety net. Journal of the American Medical Informatics Association, 2019;26(12):1525-1535.
6. Eichner JM, Johnson BH, Betts JM, et al. Patient- and family-centered care and the pediatrician’s role. Pediatrics. 2012;129:394-404.
7. Kuo DZ, Houtrow AJ, Arango P, et al. Family-centered care: Current applications and future directions in pediatric health care. Maternal and Child Health Journal. 2012;16:297-305.
8. Betancur S, Walton AL, Smith-Miller C, et al. Cultural Awareness: Ensuring High-Quality Care for Limited English Proficient Patients. Clinical Journal of Oncology Nursing. October 2020; 24(5)530-537.

Additional resource from The Joint Commission

• Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals includes toolkits and best practices related to providing safe care to LEP patients. Published in 2010.
• FAQ: Language Access and Interpreter Services – Understanding The Requirements. What are the key points organizations must consider when interpreter services are provided by staff and practitioners?

Note: This is not an all-inclusive list.