The recommendations for addressing some of the most prevalent challenges to language access in healthcare, as identified by the stakeholders and outlined in this document, were developed by workgroups at the fifth annual International Language Services Conference® (ILSC). The conference took place on October 14, 2016, in Houston, Texas. The organizers of the conference, as part of their preparations, circulated a survey among various stakeholder groups of the healthcare interpreted encounter in order to identify their major challenges. A surprising discovery was the apparent overlap of similar challenges experienced by different stakeholder groups. The resulting topic domains are shown below:
- Competency and Qualifications
- Integrating Language Access into Healthcare
- Fiscal Challenges
The workgroup format was a new addition to the event. The participants at the conference included interpreters, hospital administrators, healthcare staff, consumers of language access services, interpreter educators and case managers. Before they began the discussion of their selected topics in small groups, the participants had the opportunity to hear from one or more representatives from each represented stakeholder group. This process allowed for the development of recommendations that would acknowledge and address the interests of all stakeholder groups of the interpreted healthcare encounter. Dialogue was enhanced by the presenters’ shared personal and anecdotal experiences as well as their subject-matter expertise. The resulting recommendations ranged from building public awareness to enhanced professionalization throughout the industry.
- To increase awareness and visibility of language access by forming a language access cooperative and thereby ensure that the agreed best practices are carried out;
- To empower LEP and Deaf patients by educating them in regard to their rights;
- To research and collect data in order to make a data-driven case for changes in legislation and for the incorporation of best practices in all aspects of language access;
- To assess interpreters, providers and other staff using task-authentic assessments that emphasize the skills required in a clinical encounter;
- To enhance interpreter education by extending the duration of ITPs (interpreter training programs), incorporating practicum and internships into the curriculum and raising the minimum education requirement from a high-school diploma to a bachelor’s degree; and
- To promote multidirectional education that includes soft skills for providers/clinicians, patients, administration, HR, interpreters and translators.
The organizers of the fifth International Language Services Conference® felt it was critically important that the event depart from a perceived industry trend of speaking on behalf of stakeholder groups (LEP patients, Deaf consumers, healthcare providers, etc.) instead of hearing their own viewpoints directly. The organizers have been largely inspired by two growing bodies of work: Robyn Dean and Robert Pollard’s scholarly article titled “ContextBased Ethical Reasoning in Interpreting,”1 and the theory called systems thinking, which pertains to organizational change and development. They sought to apply the concepts beyond their intended uses in order to suggest a model for progression in the language access industry.
Additionally, the organizers wanted to referentially apply Dean and Pollard’s work to suggest a common nomenclature for interpreters of all languages that would encourage conversation beyond the habit of answering difficult questions with “It depends,” which, as Whitney Gissell emphasized in her concluding remarks, will “advance our profession through usage of common language.” What the organizers envisioned was an event that would help to facilitate more nuanced understanding, creative problem-solving and more effective collaboration so that the industry could progress beyond “it depends,” not only in terms of ethical reasoning but also in systems thinking2, moving toward more concrete recommendations that address challenges and demands so as to ultimately achieve effective practice.
Thus, the planning committee opted for the systems-thinking approach, as it would give all participants the opportunity to access a 360-degree view of the healthcare interpreting encounter. Then, with a broadened perspective, the participants had the opportunity to collaborate with representatives from diverse stakeholder groups, through which effort they could develop and recommend solutions for some of the most pressing challenges in language access that were actionable and considerate of other stakeholders’ needs.
What Is Systems Thinking?
Systems thinking is a technique that requires a thorough analysis of the relationship between the different components of a system (i.e. interpreters, patients, providers, healthcare administrators, legislators, etc.).
- It is a tool for systems analysis that helps a person see overall system patterns, structures and cycles;
- It allows language access professionals to understand the systems in which they work in order to effect change;
- It asks participants to consider all factors that impact effective practice;
- It seeks leverage points and solutions;
- It operates on the understanding that individual actions can impact the system; and
- It demands teleological reasoning.
What Is Teleological Reasoning?
Teleological reasoning is outcomes-based. While deontological reasoning is rulebased—referring only to the interpreter code of ethics to determine how to navigate an ethical dilemma—teleological reasoning is based on the rules. For example, the standards of practice and/or code of ethics for professional interpreters would set the foundation for teleological reasoning when confronting the challenges presented in this paper. But beyond that, teleological reasoning asks that we consider everything in the interpreting system. In order for diverse stakeholder workgroups to address the challenges and demands identified before and at the event, teleological reasoning was encouraged to help participants move beyond “by the book” thinking and to allow for more creative problem-solving.
Identifying the Challenges
The systems thinking approach was incorporated into every aspect of the conference, including the selection of the most pressing challenges our industry faces. In order to name the “demands,” or factors that impact effective practice in this systems approach, a three-question survey was circulated among organizations and individuals representing each of the stakeholder groups: interpreters, hospital administrators, healthcare staff, consumers of language access services, interpreter educators and case managers. The participants were asked to (1) identify their stakeholder role in language access; (2) describe what they perceived to be their biggest challenge(s) in that role; and (3) name the topics they would like to discuss at a roundtable discussion with other industry stakeholders. Question number one prompted participants to select one or more stakeholder positions from a list to best describe their role. Questions number two and three were answered in a free-response format. Eighty-nine language access stakeholders responded.
Greatest Challenge in #LanguageAccess
The organization of unique responses was employed through a broad approach (i.e., the systems thinking theory) that considered the underlying or root concern by identifying the interaction and interdependence among all responses, whereby the demands were grouped into the six categories displayed on the graph shown above.
The categories are defined below:
Competency and Qualifications: Concerns skills and qualifications of practicing interpreters, interpreter candidates and bilingual providers; interpreter training programs; and the cultural competency of all stakeholders:
Integrating Language Access into Healthcare: Pertaining to the provision of linguistically appropriate services, incorporation of best practices for providing language access and inclusion of the interpreter into the healthcare team:
Fiscal Impact: Addressing budgetary restrictions and burdens faced by hospital organizations as well as comments relating to the impact inadequate compensation has on the retention of qualified interpreters:
The Role of the Interpreter: Pertaining to the lack of understanding or misunderstanding of the role of the interpreter in the healthcare setting by provider or interpreter:
Compliance with and understanding requirements: Concerning the awareness of federal, state and local requirements as well as compliance with said requirements:
Finally, we applied the same categories to the organization of the responses collected for question number three in order to identify and rank which topic areas the participants most wanted to discuss at the conference. They were “Competency and Qualifications,” “Integrating Language Access into Healthcare” and “Fiscal Impact.”
Katharine Allen, co-founder of InterpretAmerica, in response to the conference’s morning presentations, lent her experience and expertise in this conference format to ignite the workgroup sessions. She presented an introduction to the workgroups, laying a foundation for effective collaboration toward actionable solutions.
The conference participants indicated their preference for a workgroup topic from the three listed above. This allowed conference organizers to designate the correct number of workgroups for each topic based on level of interest. Topic number one (Competency and Qualifications) had five dedicated tables; topic number two (Integrating Language Access into Healthcare) had four tables; and topic number three (Fiscal Impact) had two. The workgroup sizes ranged from six to nine participants from various backgrounds (see appendix A). In order to promote a variety of perspectives in each workgroup, the participants were encouraged to sit at tables along with participants they did not already know.
Each workgroup had a moderator and a transcriber. The workgroup facilitators were selected prior to the conference and received training and instructions. Their role was to designate a scribe and encourage productive and dynamic collaboration. The objectives provided to all workgroups were: (1) to understand each other’s perspectives regarding challenges in language access; and (2) to work together to develop possible solutions to alleviate these challenges using the information presented by the speakers and their own personal experiences.
Each moderator briefly introduced the topic by providing a short description and then posed three questions to be used as a starting point for their discussion.
1. Competency and Qualifications
This topic encompassed the challenges and concerns regarding the skills and qualifications of interpreters, staff and providers. Additional considerations are interpreter training programs and cultural competency. The participants were to take into account the testing and training requirements established by Health and Human Services and accrediting organizations, as well as recommendations made by interpreter organizations, certification bodies and other organizations, e.g., the Texas Advisory Committee on Qualifications for Health Care Interpreters and Translators.
- How can we have well-trained, qualified interpreters?
- How can we help doctors be more culturally responsive?
- How can we find/qualify bilingual providers to communicate directly with patients?
2. Integrating Language Access into Healthcare
This topic included the challenges associated with the provision of linguistically appropriate services, the incorporation of best practices for providing language access and the inclusion of interpreter services into healthcare and the treatment team. The participants were instructed to consider all variables that may influence or aggravate this challenge.
- How can interpreters be incorporated into the healthcare team?
- What set of best practices should be followed in providing language access?
- How can providers be motivated to use interpreters in all encounters with LEP, Deaf, and hard of hearing patients?
3. Fiscal Impact
This topic encompassed the challenges regarding the budgetary restrictions and financial challenges faced by hospital organizations in funding their language access plans as well as the impact that inadequate compensation has on the retention of qualified interpreters. The participants were asked to consider legal and other restrictions associated with the collection of funds in compliance with federal regulations, as well as labor laws and other factors. Lastly, the participants were asked to consider how this impacts staff and freelance interpreters.
- What are the financial issues that impact interpreters? How can we solve them?
- What are the financial issues that impact hospitals?
- Is reimbursement a viable option?
The actionable solutions developed by the workgroups can be grouped into two categories: “Building Public Awareness” and “The Professionalization of Our Industry.”
Building Public Awareness
Each of the groups that addressed the topic “Fiscal Challenges” as well as two groups that addressed the topic “Integrating Language Access into Healthcare” and one that discussed the topic “Competency and Qualifications” provided recommendations specific to the need to build public awareness. To achieve this, two specific recommendations where suggested: direct outreach and data collection.
A group discussing the integration of language access into healthcare—including the hiring manager for a language services provider, the manager of language access in a hospital system, a lead staff healthcare interpreter, a registered nurse and others— suggested the formation of a language access cooperative to ensure that industry best practices would be agreed upon and implemented. Echoing the call to increase direct outreach, other groups suggested that language access professionals who are aware of the challenges and needs within the industry should contribute by “submitting abstracts at conferences of other stakeholders” and engage in “client education.” Five of the groups suggested empowering LEP, Deaf, and hard of hearing patients by educating them on their rights and the requirements of providers.
In order for the outreach to be effective, the groups further suggested the use of data that demonstrate how language access mitigates risk to hospitals and patients. Most in our industry have heard of the “intoxicado” case. Though relevant, the anecdote is now nearly 40 years old. In order to make a stronger case for the importance of language access, we can turn to the law, to financial risks and to empirical data.
Various anecdotes and publications are more recent than the well-known “Intoxicado” case. Although more work and relevant information is still needed, a 2009 publication by the NHeLP (National Health Law Program) helps consumers and providers navigate the federal laws regarding language access for people with limited English proficiency. The National Association for the Deaf published a similar question-and-answer guide to help providers and consumers navigate the Americans with Disabilities Act and other federal laws regarding language access services.
Research and Data Data-driven arguments for the importance of language access in healthcare are stronger, more effective and more current than the “Intoxicado” case in communicating the need for appropriate, effective language access programs and initiatives. Groups discussing the topics “Fiscal Impact” and “Integrating Language Access into Healthcare” recommend collecting data and conducting research as the means to present a data-driven case when advocating for change, new legislation and the establishment of best practices.
Specific to resolving fiscal challenges was the suggestion of collecting data that would demonstrate the costs associated with non-compliance, and the integration of language access into healthcare was suggested so that health risks involved with treatment complications and misdiagnoses due to inadequate language services could be documented along with anecdotal evidence (redacted for PHI) so as to advocate on behalf of patients’ communication needs. One group discussing the topic “Integrating Language Access into Healthcare” noted the need to “insist on data collection” from patients when and if they are willing to provide it.
Additionally, two groups discussing the topic “Integrating Language Access into Healthcare” made the argument for data collection in that providers and hospital administrators are more likely to respond to data that appeal to their highest values/interests. Patient satisfaction rates exemplify the kind of data that would be useful in mitigating the issues discussed. One participant suggested incentivizing the utilization of language access, recommending “patient satisfaction rates; using data; and look for ways to link data back by language to physicians.” Similarly, Table 6 recommended that making the case for language access: “data driven & results-based . . . geared toward providers.”
Finally, data collection was recommended so as to make the case for higher interpreter pay by two groups discussing challenges associated with the topic “Fiscal Impact.” Another group argued that “higher pay could correlate to higher quality interpreting”: a strong argument if there were existing data to support it. Increased interpreter pay could also lead to increased professionalization throughout the industry, which brings us to our second category of recommendations.
U.S. News & World Report has ranked the interpreter/translator career as a 6.9 overall, a fact influenced by the low scores given to “salary” and “stress.” Regarding the salary range, there is a significant gap between the industries that pay well, which the U.S. News Overview3 identifies as architectural and engineering services, both of which offer salaries that can exceed $80,000 annually. However, in a salary survey conducted in 2006by the International Medical Interpreters Association (IMIA; formerly referred to as the MMIA), 55% of staff medical interpreters reported earning $20 or less per hour and 67% of freelance medical interpreters reported earning $25 or less per hour.4 In a similar survey conducted by the IMIA in 2015, almost a decade later, the majority of interpreters reported making $25 or less per hour. 5 Additionally, the U.S. News Overview stated that the degree of opportunity for interpreters and translators is below average in regard to advancement and upward mobility.
Other research studies on interpreting include an academic paper on the job satisfaction of sign-language interpreters,6 a publication by NHeLP addressing the costs associated with inadequate language access7 and a report published by HHS that compiles information to make the case for providing language access.8
The Professionalization of Our Industry
It was not surprising that all groups discussing the topic “Competency and Qualifications” made recommendations regarding the professionalization of our industry. However, both tables discussing Fiscal Impact as well as two discussing the topic “Integrating Language Access into Healthcare” also contributed to this recommendation. All tables focused on two domains in which we can contribute to the professionalization of our industry, i.e., testing and training.
Workgroups discussing the Competency and Qualifications topic recommend administering task-authentic assessments that emphasize the skills required for a clinical encounter for interpreters. This was a recommendation that was echoed in many groups, even those discussing the topic “Integrating Language Access into Healthcare,” where it was suggested that task-authentic assessments be extended to providers and staff. Some noted that hospitals are resorting to using bilingual staff to either communicate directly with the patient or even serve as interpreters. More alarming is that some of those who serve as professional interpreters have not been tested for that role.
Some have been tested for proficiency in the second language or have demonstrated their proficiency through education and/or experience but have not been tested. These measures may not suffice as the means to ensure that an interpreter is prepared to address the environmental and paralinguistic demands of a healthcare encounter. However, testing alone does not suffice. Most of the groups that made this recommendation also addressed the need for training.
Each of the national certification assessments was designed on the basis of Job Task Analysis and thereby provides insight regarding the knowledge and skills required for interpreters. The American Translators Association (ATA) recently published an article9 comparing three certification exams for spoken language healthcare interpreters in the US. The Board for Evaluation of Interpreters (BEI), in Texas, has also recently released a certification exam10 for healthcare sign-language interpreters. By reviewing the common domains tested through these exams—consecutive interpreting, sight translation, interpreter ethics, etc.—we have a clearer understanding of what tasks must be authenticated for anyone who functions as an interpreter in the healthcare setting.
Providers and Hospital Staff
The Health and Human Services Office of Minority Health, in 2001, published the document “National Standards for Culturally and Linguistically Appropriate Services in Health Care” (generally referred to as the CLAS standards), which outline very specific recommendations for healthcare institutions, including domains in which providers and staff should be trained. These recommendations remain relevant today. In fact, in 2014 one of the largest hospital accreditation organizations—the Joint Commission—highlighted the importance of these recommendations by publishing a document11 that compared the CLAS standards to its own document published in 2015, titled “Standards for the Hospital Accreditation Program.”
The most recent change to the Affordable Care Act, Section 1557, in response to a comment, defines “qualified bilingual/multilingual staff” as an individual who “must be proficient in speaking and understanding both spoken English and at least one other spoken language, including any necessary specialized vocabulary, terminology and phraseology, and must be able to effectively, accurately and impartially communicate directly with individuals with limited English proficiency in their primary languages.”12
Two groups that discussed the topic “Competency and Qualifications” and another that discussed the topic “Fiscal Impact” agreed on the importance of education. One group specifically recommended an increase in the duration of ITPs (interpreter training programs) and the incorporation of internships and practicum as part of the curriculum. Another group, in discussion of the topic “Fiscal Impact,” suggested that in order to increase interpreter pay, we must first “increase the educational requirement from a high-school diploma to a bachelor’s degree for interpreters so that it can become a true profession.” The suggestion was echoed by the second group discussing fiscal impact, where one participant stated that “more qualifications [lead to] higher pay and status.” In addition to supporting the professionalization of the industry, a higher level of education is conducive to the integration of demand-control schema in interpreting.
One of various examples provided during one of the conference presentations was the concept of multidirectional education, which includes not only the traditional concepts and skills required for interpreters but also soft skills. Interpersonal demands are often overlooked but become very apparent in an interpreting encounter. Two of the workgroups discussing the topic “Integrating Language Access into Healthcare” recommended the integration of interpersonal skills and emotional intelligence into training, not just for interpreters and translators but also for providers/clinicians, patients, administrators and talent managers.
Currently, both of the national certification organizations for healthcare interpreters require that the individual have a high-school diploma and 40 hours of medical interpreter training. However, the first medical interpreter certification for signlanguage interpreters, developed this year by the National Center for Interpretation Testing, Research and Policy at the University of Arizona on behalf of the Texas Department of Assistive and Rehabilitative Services, Division for Rehabilitation Services, Office for Deaf and Hard of Hearing Services, requires 80 hours of instruction in medical interpreting and a minimum of an associate’s degree.13
Although the National Council on Interpreting in Health Care published standards for training healthcare interpreters in 2011, it has not put forth specific recommendations as to how long a training program should be, stating instead that it will “depend on a number of factors.” However, the standard does list a set of domains that the training should include.14 Additionally, other organizations— particularly the Advisory Committee on Qualifications for Health Care Translators and Interpreters, as established by the Texas Legislature—have published recommendations for the domains in which healthcare interpreters should receive training.15
Whitney Gissell suggested that we use teleological reasoning, which is outcome-based and effects change by considering the environment, ourselves and the paralinguistic factors as well as the relationships in the encounter, stating that it shouldn’t be only the relationships between the parties in the encounter but all of the relationships that impact language access. To that effect, Winnie Heh stated that “we all need to get together and have a very honest conversation,” which the participants of the fifth annual ILSC® accomplished. That conversation produced the concrete recommendations in this document.
Leaders in our industry have in recent years contributed to great advancements. Now, in order to build on their accomplishments, we must consider the system as whole. “It’s us who built it, so however much we want to put in it or not put in it, that’s how it gets built . . . . No matter what perspective you come from, it’s all about language access,” said InterpretAmerica™ co-president Katharine Allen during her presentation at ILSC.
Winnie Heh, a career and academic advisor with the world-renowned Middlebury Institute of International Studies at Monterey, ended her presentation with a wish that most, if not all, conference participants shared at the conference: “I hope this can generate some discussion and we can take it back and influence our respective stakeholders and help create a sustainable talent pool for our field.” We share Ms. Heh’s hope and extend an invitation to all who read this document to find a way of effecting change in language access by contributing to the implementation of one or more of these recommendations and/or by initiating a multisectoral discussion.
Appendix A: Workgroup Makeup
Competency & Qualifications
Hospital administrator, Interpreter, Professor of Interpreting and Translating, Interpreter/Translator Trainer, Freelance Translator, College Program Director: Language Services, Hospital administrator, CCHI Chair, Nurse Educator, Patient Relations Coordinator, Medical Assistant, Government Relations Specialist
Memorial Hermann Healthcare System, Texas Children’s Hospital, University of Texas Medical Branch, St. Katharine University, University of Texas San Antonio, Houston Community College, LLS Romanian, Certification Commission for Healthcare Interpreters
Integrating Language Access into Healthcare
Interpreter, Interpreter Agency owner, Interpreter Trainer, ADA officer, Manager of Language Access Division, Hospital Administrator, Registered Nurse, HR director of Language Service Provider (LSP), Web manager of LSP, Lead Staff Medical Interpreter, Health Risk Manager, Cardiac Monitor Tech, Freelance Translator, Patient Advocate, ADA Trainer, Communication Specialist, Chief of Disease Control, Client Service Specialist, Physician’s Assistant, Outreach Case Manager, Director of Language Access, Director of Patient Services, VP of Sales of Healthcare Staffing
University of Texas Medical Branch, MasterWord, St. Luke’s Memorial, Texas State Guard, Harris County Public Health, Dallas Children’s Nurses Etc.
Interpreter, Hospital Administrator, IT Provider, Interpreter Trainer, Researcher of LSP, Language Access Coordinator, Agency Recruiter.
Harris Health System, Texas Children’s Hospital, Celeo Technology, LLC, University of Texas Medical Branch, Houston Interpreter and Translator Association, Middlebury Institute of International Studies, MasterWord
- The systems thinking theory is a management technique where true understanding is gained through the analysis of the relationship between the different components of that system; in this case, the healthcare interpreted encounter.
- 2015 IMIA Compensation Survey and Status of the Profession (p. 5). International Medical Interpreters Association.
- https://ncihc.memberclicks.net/assets/documents/publications/National_Standards_5-09- 11.pdf