Effective language support rests on a foundation of accurate information about patient needs. The nurse picks up the phone to call a patient whose lab results indicate that the patient needs urgent attention. The nurse looks at the EMR to see what language that patient speaks so that she can first get a phone interpreter on the line before dialing the patient. The inpatient bedside nurse coming on shift at 7 am needs to know what interpreter language to ask for on the video remote device as he prepares to wake the patient for doctor rounds. The surgical prep team needs to know which form of sign language support is needed by the patient with hearing and vision deficit for an upcoming surgery, so that they can put in a request for an onsite interpreter ahead of time. How frustrating for staff when there is no language documented, or when the language listed is wrong or incomplete.
The Registration Director controls the collection and documentation of demographic information, which includes patient need for language support and for disability accommodation. Many patients need both, such as when a Somali-speaking patient is very Hard-of-Hearing.
The Registration Director is high in the management group. She has regular meetings with IT and is central to any new IT program implementation. She works closely with, or supervises, the chief Medical Records manager. She also manages the Admitting Department and the receptionists in the Emergency Department. Any time spent with the Registration Director educating her on the details of language support pays off very well.
Surgery, Pharmacy, and Financial Services systems may not be under Registration oversight, but these very busy departments do draw on many variables from the Admitting and Appointment systems to build their own patient accounts. In well-integrated health care systems, if the patient’s language is correctly entered in Registration files, then staff across the entire spectrum of care will see the correct language for each patient pop up on their own screens.
(Unfortunately, some surgical and pharmacy programs do not include a variable for language or for accommodation. Surgical staff and Pharmacy staff therefore have a very hard time being pro-active around language support, unless they also keep the hospital EMR system up on their workstations as well.)
The Registration Director oversees the content of training for all staff who touch the Admitting and Appointment databases, both of which ride on top of the Registration files.
Training must address the following topics:
- Questions about patient needs must be asked correctly. See below for the script.
- Entering values in specific variables according to the algorithm so that values across different variables do not contradict each other. For example, if a patient states that his preferred language for healthcare conversations is Thai, the Interpreter Needed variable must be YES.
- Staff education must compensate for the fact that most registration personnel have only a high school education, with little formal preparation in geography, anthropology, world history, or a foreign language. Most frontline staff do not speak a second language. Most are young and do not have a sensory deficit, because they would not be able to perform the job functions if they did. Most do not have any clinical patient care experience. As a result, staff may register English-speaking patients who have had a stroke as needing an interpreter, realizing that the patient needs additional help in communicating but not understanding what the function of an interpreter is. Or staff resist registering a patient as needing an interpreter because the patient is able to make himself understood on simple topics such as setting an appointment time, not understanding that healthcare discussions involve a much more complex use of language.
- The Language Program Manager should ask to be included on the committee to set the Registration training curriculum.
Registration training needs to include the following fundamentals:
- A description of which language communities make up the client base of the particular health organization, including what countries these communities come from. Staff need to learn that some countries have many language groups, and that some language groups such as Spanish, French, and Arabic speakers come from many different countries. Staff should document all of the languages that the patient would be comfortable discussing health care matters in with their care team. For example, a Somali refugee who grew up in Kenya may prefer to speak either Somali or Swahili with her care team. Use an FYI field or a Comment field to add the additional languages if there is no room in the primary language field.
- The question about preferred language needs to be phrased thus: “What language do you prefer to use to communicate with your care team?” (Do NOT ask what language the patient speaks at home. This is NOT what we need to know.)
- It is important to document the language needed, not the name of the country or region the person comes from. Example: A person speaks Cantonese, which is a spoken language, not Chinese, which is a nationality. A person speaks Amharic or Oromo or Tigrigna, which are languages, not Ethiopian, which is a country. Staff need to look up the language if not clear if it is a language or how to spell it. Example: The patient may speak a language from hill country in Burma which is called Chin. This is not Chinese. By looking this up, the staff person will be assured that he has heard correctly from the patient that a Chin interpreter is needed.
If the facility also documents written language, this may be different from the patient’s documented spoken language.
Many people who prefer using the spoken language of their home country of Burma, Malaysia, or Cambodia prefer written Chinese, traditional format, as their language for written health materials. (Note: Chinese is not a spoken language. It IS a written language. For written language, the person uses either traditional or simplified Chinese characters, which are different.)
What reference materials are available to people entering data into the registration system to look up an unknown language or one not on the menu? Do they have access to Google to look languages up on the Internet?
The Registration Director knows how incoming patient referrals from the community are registered as new patients. Does the referral template used by outside referring doctors have a space for patient’s language need and accommodation need? Language need for new patients is often not recognized because it is not included on those referral documents.
Are newborns registered properly for language support for mom and dad? When does this registration happen, and by whom? In some systems newborns do not have a language registered until their parent takes them in to the clinic and the need for interpreter support becomes clear. In other systems a newborn’s language is set by (incorrect) default to English, no interpreter needed, based on the assumption that no one is going to talk to the newborn and thus ignoring the language needs of the parents. Best practice is to have every newborn registration checked for language need of the mother, at least. If registration of the baby is done at mom’s bedside by the Admitting clerk, mom should be asked whether any parent or guardian will need language support for bringing the baby in for care or for caring for the baby in the hospital right after birth. Language support is critical in the NICU, for example.
Are the language designators properly set up in both the Registration template and the Appointment template? Are the language menus for staff to choose from clean, with only valid choices? Make sure that all of the languages needed for this particular hospital’s patient population are on the menu, whatever those are. Make sure that there is a way to register languages which are NOT on the menu, such as by registering OTHER with a typed-in description of the needed language(s). Do the language designators show up on the header of the patient record so that all staff and providers see language need on every page?
Are sensory deficit designators available: hearing deficit, vision deficit, speech deficit? Are instructions on asking patients about their need for accommodation well thought out? Are there registration soft stops or hard stops for language or sensory deficit?
The Registration Director is the best ally of the Language Program Manager to get the correct programming of all of these variables into the registration database, as well as to create robust training for staff on how to ask patients about their language and accommodation needs.
The Registration Director also probably owns the variable called Permanent Comment, or FYI. This comment space is often not used because administration is concerned that staff will enter inappropriate comments there, which all staff can see and which might be visible to the patient when checking in or using the portal. Rather than wasting this very useful comment box, which allows for detailed and specific documentation of the patient’s accommodation or communication needs, direction is provided on what types of comments are to be included. Monthly audits of what is in this variable can be conducted, to monitor and correct anything inappropriate. Entries can be traced to the specific staff person who misused the space.
Accountability for bad registrations needs to be structured through audits. Patterns of bad and incomplete registrations can be identified through the registration tracking system in every appointment and EMR program. An audit can identify contradictory pairings of variables, such as Interpreter Needed– No plus a foreign language, or English plus Interpreter Needed Yes, or no sensory deficit plus ASL. Audits can also identify wrong language designators, which happen when there are garbage items in the menu that staff can choose, such as Chinese or Ethiopian.
Accountability can also be enforced by looking at the history of who made changes to a variable. This is the purview of the Registration Department. For example, a receptionist in the Dermatology Clinic, or a receptionist in the Emergency Department, may be consistently making registration mistakes by not asking the language support questions correctly. The Language Program Manager should educate and re-educate the Registration Director on how to raise this issue with the relevant supervisor over the staff person who is making registration mistakes. Thus, all three levels of staff are educated by the Language Program Manager: Registration Director, clinic or unit supervisor, and frontline staff person. It is useful to have a generalized teaching pamphlet or PPT to show bad registrations versus good registrations, so that many issues related to language support and accommodation registrations can be re-enforced.