Patient safety has been a prime issue in health care since the 1999 Institute of Medicine (IOM) report To Err is Human, which led to adverse event tracking and quality improvement measures in almost every facet of health care delivery. One facet that poses a challenge includes native and spoken language.
Patients for whom English is not their primary language and who have difficulty communicating in English present unique challenges in the provision of safe, high-quality care. The U.S. Department of Health and Human Services (HHS) refers to this barrier to care as Limited English Proficiency (LEP). Historically, the safety issues relating to LEP patients have not been adequately tracked or considered in quality improvement assessments.1 Patient safety could be jeopardized because of missed portions of the history and physical examination, omitted details, and lack of clarity of discharge instructions, to name a few possible reasons. As a result, patient safety can be jeopardized due to language barriers, particularly in the noisy, chaotic environment of an emergency department where the need for timely and effective communication is paramount.
Imagine the following clinical scenario:
You are a patient with LEP; Spanish is your primary language, and you called 911 because you have had fever, a cough, and shortness of breath. You did not go to the doctor’s office because you lack insurance, you have a busy work/family schedule, and you certainly wanted to avoid the expense of an ED visit. You are picked up by EMS who recognize your distress, put a non-rebreather on you, but you cannot communicate with one another due to the language barrier. Imagine how scared you must be.
When you arrive in the emergency department, health care workers bustle around you; they put in IVs, get a chest x-ray, EKG, draw blood cultures, and ask you about your health problems. Your physician attempts to use the interpreter phone, but the interpreter can’t hear you over the non-rebreather, so they search for someone with Spanish-speaking ability in the department. One of the staff members in broken, high-school level Spanish is able to determine a very basic story, but misses vital components of your past medical history, current meds, and symptoms leading to your 911 call.
For many LEP patients, this is their emergency department experience. Even though language assistance is mandated under Title VI of the 1964 Civil Rights Act, inadequate interpretation is an unfortunate reality. Consequently, it should be no surprise that LEP patients have less understanding of their medical conditions, higher rates of ED recidivism, and worse outcomes than their English proficient counterparts.2 Health equity for LEP patients is a complex, multifaceted problem, with quality interpretation being just one part of the puzzle. The purpose of this article is to give concrete suggestions for learning about language access in your department and becoming a local advocate for language justice.
First, when a patient comes through your hospital’s doors, does a nurse or registration worker ask, “What’s your preferred language?” If the response is anything other than English, do they follow up with, “Would you like an interpreter during your visit today?”2
Next, look at how physicians and nurses obtain the services of an interpreter, either through a phone/video service or an in-person interpreter. As providers, we know that LEP patients are safer with a Certified Healthcare Interpreter (CHI), but you may find that there is no consistent procedure for using their services. Instead, we often try to “get by” either with our own basic-intermediate language skills or those of other staff members.1 Hospital staff may also use a family member or friend to act as an interpreter. However, this approach is problematic because many ad hoc interpreters have no training in interpretation, are not a neutral party, may have limited exposure in health care, and are likely to be emotionally distressed by the situation.
To better understand your institution’s approach to LEP interpretation, review any relevant hospital policies and inquire whether there is a specific department dedicated to language services. Talk with colleagues both within your department and other specialties, including nursing and ancillary staff, about their experiences and concerns. Gather information from an interdisciplinary group is integral in advocating for improvements.
Because the care of LEP patients touches all parts of the health care system, it is important to develop a broad base of support for this important issue. If your institution has in-person CHIs, speak with them about their experience, how they view hospital interpreter use, and what improvements they would like to see. Often, they are the most knowledgeable about language barriers to care. Also, ask your ED Operations or Safety/Quality Improvement Department if there have been previous quality improvement projects to address the needs of LEP patients. Especially if you use your own non-English language skills in the clinical setting, be sure to review your health system’s policy on bilingual clinicians. In many systems, a bilingual exam is available to become a certified bilingual provider. However, if you use your non-English language skills without certification, the health system may fault you if the case has a bad outcome.
When LEP patients visit the hospital, we know their outcomes and overall experience are not equal to that of their English-speaking peers. Regardless of where you are doing your emergency medicine residency, our country’s demographics are changing and it is incumbent upon us to provide high quality care to every patient, regardless of language spoken.
As emergency physicians, we treat patients when they are most vulnerable. Put yourself in their shoes, exercise curiosity about your institution’s policies and performance regarding LEP patient care, and you will likely find areas for improvement. With this information, you can become an advocate for meaningful change and propose solutions that are supported by an interdisciplinary team of fellow advocates dedicated to providing more equitable, compassionate care.
- Price-Wise, Gail. Intoxicating Error: Mistranslation, Medical Malpractice, and Prejudice. Bookbaby, 2015.
- Betancourt JR, Renfrew MR, Green AR, et al. Improving patient safety systems for patients with limited English proficiency: a guide for hospitals. (Prepared by the Disparities Solutions Center, Mongan Institute for Health Policy and Massachusetts General Hospital and Abt Associates, Cambridge, MA, under Contract No. HHSA290200600011I). Rockville, MD: Agency for Healthcare Research and Quality; AHRQ Publication No. 12-0041. September 2012. https://www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
- Wasserman M, Renfrew MR, Green AR, Lopez L, Tan-McGrory A, Brach C, Betancourt JR: Identifying and Preventing Medical Errors in Patients With Limited English Proficiency: Key Findings and Tools for the Field. J Healthcare Qual. 2014, 36 (3): 5-16. 10.1111/jhq.12065.
- Taira BR, Orue A. Language assistance for limited English proficiency patients in a public ED: determining the unmet need. BMC Health Serv Res. 2019;19(1):56.