Balancing Internal & External Resources to Manage Cost and Effectiveness

Language program managers need to create, maintain, and modernize their programs to keep up with both regulatory and institutional needs. They need to present and defend their budgets every year, often to administrators who are unfamiliar with the landscape of language support. In this process, they face several challenges, including:

How to decide the balance of services?

How to contain costs for language support while providing effective communication at all points of service?

When to add new contracts to assure full functionality?

How to fully use staff time between specific patient assignments?

Here are several elements to consider for Language Support Programs:

Size of the language access program

How many patients are there who need language support, how many encounters are there requiring support, what percentage of the patient base requires language support? Is the present size of the language support program about right, is it short of what is needed, is it over-funded or over-staffed? Language access managers must look at these questions within their institutions as well as considering what other institutions in the region have. They must defend budget requests not only to assure that they have enough resources for their patients, but to explain why they would be worried to reduce support to levels considered adequate in other institutions.

Complexity of the language access program

How many different environments of care must be supported—outpatient routine medical visits, significant outpatient procedure areas (colonoscopies, derm surgery, amniocentesis, etc.), group education or therapy programs, full surgical programs, day surgery (infusion, dialysis, interventional radiology), imaging and testing (cardiac stress tests/ultrasound/cath, angiography, CT and MRI), inpatient units (medical, surgical, neonatal, trauma, mental health), international health, hospice? Many of the specialized programs noted here require in-person interpreting if possible. If not possible, the complexity of the care requires highly competent and maybe specialized remote interpreters. The more complex the programs, the higher the need for translated patient education and consent forms.

Reporting structure

Is the language support program located within Patient Access, Medical Staff, Compliance, Nursing, etc.? The reporting structure can influence what the language access program focuses on. Many hospitals have separate chains of command for inpatient services versus outpatient services, as well as separate silos for imaging and surgery. Whichever silo the Interpreter Services manager reports up through, it is important to make sure that the other silos are also receiving the language support needed by patients and providers. For example, if the Interpreter Manager reports up through the Clinic side, very often mechanisms to support inpatient interpreting and translation are less robust than they should be. If it reports up through Risk Management there may be more emphasis on checking off boxes such as policies rather than strong connections with the clinical departments where patients are seen.

Maturity of the program

Does the organization have a strong history of language support? Are doctors and staff experienced in using both staff and agency in-person interpreters, as well as different modalities of interpretation? Or is the organization struggling to even introduce the concept of professional language support at all of the patient interfaces? It may be critical to have staff interpreters ready to deploy instantly to the units that are just getting used to using professional interpreter instead of family, as the added layer of requesting from an agency may be too much for staff to get done.

Organizational attention to patient education

Is there an established internal translation program? Do clinical units know how to make request? Or does the Interpreter Manager perform the critical function of helping units prepare materials to send out to a professional translation agency? We hope over time to research whether patients who received translated materials did better clinically than patients who received materials in English.

Budget pressures

Language access programs have Staff costs and Purchased Services costs, as well as equipment costs. It is common to centralize costs for language support in a Language Support department so that clinical units are not tempted to trim their own budgets by not using language support. Balancing of demands must be done. For example, ASL interpreting costs more per hour than foreign language interpreting, and both Deaf patients and immigrant patients must have their needs covered. Mental health programs require high dollars for language support because only in-person interpreting is used, and patients often undergo weeks or months of all-day therapy. Often translation receives insufficient or no financial support, particularly in immature programs. The language program must juggle which languages to support with staff interpreters versus which languages to support using agency or remote means.

Patient groups requiring higher-than-average resources

Some language groups in which few people are scientifically educated and which therefore have few or no competent medical interpreters are very difficult to provide language support for. The Interpreter Manager needs to inventory how many such patients are seen by the organization in order to plan for an appropriate mix of staff and agency interpreters. It may be worth it to hire a staff interpreter in one of these rarer languages just to make sure the community can receive language support at this facility, even if this interpreter is not kept busy with interpreting all the time.

Room for staff

Room for staff interpreters and translators: In order to use staff interpreters and translators, physical space must be available for them in base areas with room for storing outerwear, doing required computerized administrative tasks, taking breaks, performing translation, and performing phone and video interpretation in booths. Space constraints can fatally crimp the effectiveness and productivity of staff. The manager must also be close to the activities of the staff interpreters and translators to be effective.

HR support

HR support for interpreter and translator staff: Once a language support program has hired its first interpreters, translators, schedulers, and managers it is easy to simply adjust the fine points of their job descriptions and the number of staff employed. However, it can take years to create and get administrative support for first setting up the staff components of a language support program. For instance, if some or all staff are unionized, it can be difficult to assign the interpreters, translators, and schedulers to appropriate union staff categories. If union wage levels dictate wages that are too low to attract good candidates from the community, these positions will be very hard to fill because interpreters can make more through agency. This is particularly true for ASL interpreters and for translators, so many programs never include ASL interpreters or foreign language translators on staff.

HR support can make or break a language support program. If HR understands the value of professional interpreters over using ad hoc untrained bilingual staff, they will commit to assuring that staff interpreters have acceptable working conditions, continuing education opportunities, and pathways to higher professional development like other categories of health care staff do. HR recruiters should be mentored by the language access manager to screen for the important factors of proven dual language proficiency, ethical performance, training in interpreter fundamentals, attainment of state or national certification, and experience in many different health settings.

Mix and cost of agency resources available

The local area may have few or many qualified interpreters available to come in-person. Local agencies may be too expensive to use OR there may be a vendor leading a race to the bottom of hourly charges while basing that on the use of untrained and incompetent interpreters.  The balance of in-person to remote modalities greatly depends on what languages are available at affordable cost and at high enough quality. As local agency charges rise, organizations shift the balance away from in-person to staff interpreters and remote agency modalities. The balance between using agency or staff can swing back and forth every few years. The interpreter manager must build good relations with contracted agencies so that both organizations can plan their business relationship for the next few years.

Contracting support

Contracting support to achieve suitable contracts with agencies: Some healthcare organizations manage their contracting with vendors through a Contracting department rather than through the Interpreter manager. In some cases, such as with governmental health entities, there is a requirement to contract with the lowest bidder, even when that bidder cannot demonstrate required quality or quantity of performance. This forces the Interpreter manager to use more staff, who can be trained and monitored. Some organizations, however, allow contracting to fully serve language support needs. For example, a large hospital system may need three or four agencies to provide a full mix of the languages needed in-person, as well as several different remote agencies to provide telephonic and video interpretation across the languages needed. Every agency provides a different mix of languages, as well as a different standard of quality. As the demand for more specialized interpreter qualifications grows, some agencies may begin to provide only interpreters with more specialized, and more expensive skills. One or more translation agencies will also be contracted with, based on their ability to perform on healthcare content.

What other things do you consider while preparing your plan? Let us know in the comments below!

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