0 Language Services: The Why and the How April 2013

Objectives Recognize the importance of providing culturally and linguistically appropriate services Explain the role of the patient and companion in determining what services are required for effective communication Identify the laws governing language services Identify four ways to access spoken language interpreter services at Inova Describe the five steps to follow in providing services to the Deaf or Hard of Hearing Explain how to arrange for sign language interpreters and/or auxiliary aids at Inova

ATTENTION! PLEASE NOTE: This module details the processes required in using the paper forms. Use of the related Epic flows will be taught separately at each OU or other entity and to the appropriate staff as Epic rolls out across the System.

3 Northern Virginia: An International Community Highly diverse community of approximately 2,623,079 people 45% of the people identify with a minority group Approximately 24% are foreign born Over 33% speak a language other than English at home; 12% speak English “less than very well” Among the most common foreign languages spoken at home in Northern Virginia are: The region we serve – Spanish – Amharic – Chinese – Korean – Vietnamese – Arabic – Farsi – Urdu * Census 2010 and ACS 2011, 5-year estimate

4 Office of Health Equity (OHE) Vision: A community where all residents have access to resources that promote and sustain health and well being. Mission: To create a community where systemic and avoidable health disparities are steadily reduced, so that the gap between the best and worst off is narrowed; all residents have equitable access to a full range of high-quality healthcare and support; all have equal opportunities for optimal health and well being

Office of Health Equity Selected Office of Health Equity Programs and Services Language Services Spoken language interpretation Sign Language interpretation and the provision of other services for the deaf or hard of hearing Translation of vital documents Training and Education Diversity, Cultural Competence and Health Equity Education 21 st Century Leadership Development Now We’re Talking! Bi-lingual staff interpreter training

Patient-Centered Care and Effective Communication

7 Patient-Centered Care and Cultural Competence you The “truth” Experiences Perceived Reality you The “truth” Patient-Centered Care Is by definition culturally and linguistically appropriate Ensures that patients, companions and providers partner in care and explore all health options Is delivered in a manner that meets patient preferences Is deeply respectful of patient and family values, beliefs and traditions

8 Patient-Centered Care & Effective Communication Patient centered care requires effective communication Effective communication requires that information is understood by all parties involved in care AND Understood thoroughly enough that the parties can use or act upon information exchanged This is true for all patients regardless of race, ethnicity, age, gender, education, religion, socio-economic status, language spoken, etc.

Laws Governing Language Services

10 Spoken Language No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. Language is considered a proxy for national origin. (precedent, beginning 1926) We must provide the same quality care regardless of and language spoken Enforced by the Office for Civil Rights (OCR) Title VI of the Civil Rights Act of 1964

11 Spoken Language: Highlights of Title VI Trained medical interpreters must be provided to our Limited English proficient patients at no cost to the patient A person who is limited English proficient either does not speak English or speaks English “less than very well.” Vital documents must be translated and communicated in patient’s language, including: application and enrollment forms letters or notices regarding eligibility or changes in benefits anything requiring a response patient consent forms documents of a legal or financial nature

Sign Language/Services for Deaf or Hard of Hearing No individual may be discriminated against in the full and equal enjoyment of goods, services, facilities, privileges and accommodations in privately operated commercial facilities that are open to the public. ADA ensures equal access to goods and services for persons who are deaf or hard of hearing ADA requires effective communication, and the provision of appropriate auxiliary aids and services (including qualified interpreters) when necessary to ensure effective communication for patients with disabilities Enforced by the Department of Justice (DoJ) Title III of the Americans with Disabilities Act (ADA)

What is a Companion under the law? Companions must be offered language assistance The term “Companion” means: a person who is limited English proficient or deaf or hard of hearing and needs to communicate with the staff about the patient’s care Includes but is not limited to: Someone who assists in providing care or comfort Someone who assists in decision-making Legal guardian Power of Attorney Disclosure of information to the Companion is governed by HIPAA If there is a question as to whether the individual meets the definition above, consider the individual a companion

14 Interpreter Policy Summary Any patient and/or companion who is limited English proficient or deaf or hard of hearing must be offered interpreter services or auxiliary aids free of charge Interpreter services must be provided by trained interpreters Friends and family may not be used as interpreters unless specifically requested by the patient and charted accordingly Minor children should never be used as interpreters In an extreme emergency, render any necessary and appropriate medical treatment and use your best efforts to provide the most effective communication possible until the interpreter arrives

Language Services: Spoken Language: Your Responsibilities

Spoken Language: Your Responsibilities 16 1.Complete a communication assessment 2.Secure needed interpreters 3.Complete the necessary documentation

Step 1: Spoken Language Assessment The question to ask is: “In what language do you prefer to talk with your doctors or nurses?” Rely on the patient’s or companion’s own assessment of his/her English proficiency in determining the need for an interpreter. Document the patient’s preference in the patient’s record. All Patients must be asked their language preference

Step 2: Secure Interpreter Services If a patient or companion indicates a language preference other than English Staff Interpreters (Spanish) Inova staff interpreters in Spanish are available on all Inova hospital campuses A complete list with hours of coverage and phone numbers can be found on InovaNet: Call the appropriate extension to obtain a staff interpreter at your location

Services available at ALL Inova facilities in multiple languages: Contracted, On-Site Interpreters To pre-schedule an interpreter, access the “Inova Interpreter Request” on InovaNet If the request requires an immediate response, use the Language Bank, the interpreter phones or call the Scheduler at (Option 2) Step 2: Secure Interpreter Services Inova Interpreter Request Request/LangRequest.html If patient or companion prefers a language other than English

Services available at ALL Inova facilities in multiple languages: Volunteer Interpreters who have completed 40-hour medical interpreter training. Search “Language Bank” on InovaNet Over 600 volunteer interpreters in 45 languages Telephonic Interpretation (Interpreter phones) Available 24/7 in 170 languages Step 2: Secure Interpreter Services If patient or companion prefers a language other than English

Step 3: Documentation In the patient record, document: Language preference/ requests for service Note name or identifying number of interpreter used Refusals of service and how you respond Note name of individual chosen to interpret by patient and relationship to patient Emergency situation necessitate the start of care before a trained interpreter arrives. Any unusual circumstances If it isn’t documented, it didn’t happen.

Services for Deaf or Hard of Hearing: Your Responsibilities

Services for the Deaf/HoH: Your Responsibilities We must identify and assist 100% of our patients and companions who are deaf or hard of hearing. There is a 0 tolerance policy Understanding the patient’s perspective will help you understand the need to rely on the patient to tell us what services or aids are needed for effective communication.

Deaf/HoH: Your Responsibilities 24 1.Complete the necessary communication assessment 2.Secure needed resources 3.Undertake steps until an interpreter arrives 4.Adhere to necessary steps when an interpreter arrives 5.Complete all required documentation

Purpose: Allows patients and companions to identify as deaf or hard of hearing and request or decline specific services Must be completed by ALL patients At the first opportunity to assess: Provide the CRF to ALL patients ALL patients must answer two questions: 1.Are you or any of your companions deaf? 2.Are you or any of your companions hard of hearing? Step 1: Communication Assessment Deaf or Hard of Hearing Communication Request Form (CRF)

Deaf or Hard of Hearing Communication Request Form Patient may indicate that the form stands for the current course of treatment This refers to certain hospital-based series accounts These accounts reset at the first of each month. If a patient is readmitted after the account resets, he or she will be required to complete a new CRF Step 1: Communication Assessment

Only the top section of the CRF needs to be completed. The patient must sign and date the form and note the time. Hospital personnel must also sign and date the form and indicate contact information. The process is complete. Maintain the completed form in the patient record (fax to Medical Records) If neither patient nor companion(s) is deaf or hard of hearing: Step 1: Communication Assessment

When a Patient or Companion is Deaf or Hard of Hearing Any patient or companion who is deaf or hard of hearing must complete the middle section of the CRF. Purpose: This allows the individual who is deaf or hard of hearing to: Request specific services and/or auxiliary aids Decline services 28 Deaf or Hard of Hearing Communication Request Form: Step 1: Communication Assessment

Deaf or Hard of Hearing Communication Request Form The request MUST be based on the patient or companion preferences Never try to dissuade a patient or companion from requesting a specific service or aid If circumstances do not allow for the form to be completed by the patient or companion, you may assist in completing the form The patient or companion must sign and date the form and indicate the time of completion Hospital personnel must also sign and date the form and include contact information Maintain the completed form in the patient record (fax to Medical Records) 29 Step 1: Communication Assessment

Deaf or Hard of Hearing Communication Request Form The CRF has a second page, the FAQ’s/Complaint Resolution Process Detach page 2 and provide this to the patient or companion For any paper chart, you must also complete and affix to the chart the Deaf/HOH Chart Flag (yellow 8 ½ x 14” form) 30 Step 1: Communication Assessment

Deaf/HoH Patient and/or Companion Identifier Any patient or companion who is deaf or hard of hearing must be offered a visual identifier. Use orange wrist bands for this purpose. Patient or companion is deaf: Use the band with the symbol indicating deafness. Patient or companion is hard of hearing: Use the band that has “HOH.” 31 Step 1: Communication Assessment

Deaf or Hard of Hearing Communication Request Form If a patient identifies a deaf or hard of hearing companion who is not at the hospital, but will require service upon arrival, staff must: Provide the patient with the contact information for anyone on the unit who can assist the companion in completing the Deaf or Hard of Hearing Communication Request Form (CRF) and/or Provide the CRF to the companion when he/she identifies him/herself 32 Step 1: Communication Assessment

33 In a public area: If you are approached by an individual who is deaf or hard of hearing in a public area of the hospital, help the person locate appropriate staff to assist in completing forms and getting services. Examples of how you may help include: Accompany the patient/companion to an appropriate unit in the hospital (for example, assigned unit, registration, information, etc.) Locate clinical or registration staff or unit secretaries, etc., who may be able to assist Locate a NexTalk unit that may help to facilitate discussion Exchange written notes, if appropriate, to answer immediate questions (for example, to provide directions) Rely on one another! Step 1: Communication Assessment

34 Step 2: Secure the Needed Resources Within 15 minutes from the time the completed Deaf or Hard of Hearing Communication Request Form is signed, staff must: Call to obtain a Sign Language Interpreter –System-wide phone number –Answered 24/7/365 –Use for scheduled and emergent needs –Time frame to have a Sign Language interpreter on site for emergent needs: within 2 hours signing of the Communication Request Form Within 30 minutes from the time the completed CRF is signed, staff must: Secure NexTalk video remote interpreter when requested (where available), and/or Secure the appropriate auxiliary aids/services

35 Sign Language and Oral Interpreters Video Remote Interpreters (NexTalk) TTY’s Pocketalkers (assistive amplification devices best used for moderately hearing impaired people) Written materials Telephone handset amplifiers Telephones compatible with hearing aids Closed captioning of hospital programs Virginia Relay Service -711 Pocketalker TTY These devices and services are available free of charge to patients or companions: Step 2: Secure the Needed Resources NexTalk

36 Step 3: Until the Interpreter Arrives Communicate by writing notes Use multiple means of communicating Chart all notes exchanged Use NexTalk (Video Remote Interpreting) where available In EDs, L&Ds and for check-out from Administrative Director Do not rely on lip reading Unless the patient insists it is his/her preferred method of communication Document what you do!

Step 4: When the Interpreter Arrives Sign Language Interpreter Schedule Within 90 minutes after the interpreter has been provided AND when a patient is expected to remain in the hospital 12 or more hours: Patient and/or companion must determine the Sign Language Interpreter Schedule for the expected duration of stay Base the Schedule exclusively on the - patient’s and/or companion’s wishes Staff must provide information to assist

Step 4: When the interpreter arrives Sign Language Interpreter Schedule The patient or companion and hospital personnel must sign and date the Interpreter Schedule Call to activate the completed schedule, AND Maintain the completed schedule in the patient’s medical record Provide a hard copy to the patient/companion Patients and/or companions have the right to request a change to their schedule at any time As conditions change, staff should periodically consult the patient and/or companion to assess the Interpreter Schedule and modify, if necessary. Revised schedule(s) must be called in to and maintained in the patient record (fax to Medical Records)

Step 4: When the interpreter arrives Sign Language Interpreter Schedule Staff must assist the patient and/or companion in completing the schedule by providing the following information (to the extent that it is both reasonably ascertainable and allowed under HIPAA): i.the anticipated period of time that the patient will be in the Hospital; ii.the nature of the patient’s condition, including its seriousness and stability; iii.the likelihood of needing to communicate with the patient or companion at unexpected or unforeseen times; iv.the most common hours that hospital personnel will need to communicate with the patient or companion v.the availability of 24-hour interpreter services and auxiliary aids free of charge

Step 5: Documentation Requirements In the patient chart document: All requests for or refusals of service (documented on the CRF) Your response to the such requests for or refusals of service Any notes exchanged Types of services or auxiliary aids used Any unusual circumstances If it isn’t documented, it didn’t happen.

41 Compliance with policies and procedures for the Deaf and Hard of Hearing is monitored by Inova’s ADA Compliance Officer Results of random chart audits are shared with departmental leaders for continuous ongoing quality improvement If you become aware of an instance where patients or companions did not receive their requested deaf or hard of hearing services within the required timeframes, please report this to the ADA Compliance Officer Please note: Contact information for Office of Health Equity Staff and the ADA Compliance Officer can be on InovaNet: Monitoring and Compliance

Additional Information INTERPRETER SERVICES