Doctor A: Their preferred language was Spanish, but they needed an interpreter for complex medical discussions. He was admitted for bronchiolitis, so we didn’t feel the need to use an interpreter.
Doctor B: Dad spoke English, so we used Dad as an interpreter to inform Mom about discharge instructions and medications.
Doctor C: I looked for the video interpreting device, it was not available.
Doctor D: Do I need to use an interpreter every time I enter the room?
The comments and questions above all come from providers caring for families with limited English proficiency (LEP). The United States is becoming increasingly multilingual, with >200 languages spoken. As a result, providing linguistically competent care has become a priority in health care. The 2019 United States census survey revealed that 22% (67.3 million people) of the United States population speak a language other than English at home,1,2 more than double the 11% in 1980.1 Of those who speak a language other than English at home, 38% (25.4 million people) have LEP, meaning they speak English “less than very well.”2 The proportion of patients with LEP is projected to grow in the next decade. In November 2021, the Joint Commission published a sentinel event alert requiring health care organizations to address health care disparities by improving quality and safety.3 This alert clarified the need for organizations to collect language data, assess language needs, and meet those needs by providing respectful and effective interpreter and translation services.
The Institute of Medicine first highlighted the disparities with language barriers in their groundbreaking report in 2003.4 Patients and families with LEP are at a high risk of preventable harm, encounter barriers to accessing health care services, receive a lower quality of care, and suffer worse outcomes than English-speaking families.5,6 Families with LEP are subject to inadequate or excessive testing, experience poor follow-up and discharge instruction, are often misdiagnosed, and are subject to increased medical errors.7,8 Various federal and state laws and policies mandate that health care systems provide language access to patients with LEP; however, the reality is that many struggle to fulfill this obligation.9
An approach that may help elucidate the barriers to improving care for patients with LEP comes from Bronfenbrenner’s ecological systems theory.10 The full ecological systems theory identifies 5 environmental systems with which individuals interact; however, even breaking the system down into the individual, micro, and macro level may be illuminating (Fig 1). In the subsequent paragraphs, we discuss some challenges faced at multiple levels. Additionally, Table 1 lists potential solutions to these challenges to improve the unequal care received by families with LEP (Table 1).
Influence of various system to improve care of patients/families with LEP based on Bronfenbrenner's Ecological Systems Theory.
Influence of various system to improve care of patients/families with LEP based on Bronfenbrenner's Ecological Systems Theory.
Challenges and Proposed Solutions to Improve Care of Linguistic Services in Hospitalized Children
| Challenges | Providers | Institutions | Policymakers |
|---|---|---|---|
| Variability in scope and impact of state legislation with only 29 states addressing services exclusively for children, almost none in an inpatient setting26 | Familiarize with legislation at local area of practice | Improve awareness within institution about federal and state specific laws regarding language assistance services | All states to enact regulations, broaden and clarify the federal legislations related to children and hospitalization |
| Familiarize with institutional policies related to care of families with LEP | Inform patients about their rights to access services | Legislation should be focused to address the larger issue of interpreter service and not be limited to specific language/disease/payer | |
| Inconsistent enforcement and implementation of policies | Be aware of the policies and implement them on front lines | Provide clear policies and improve accountability by reinforcing the policies | Consistent reinforcement of the policies undertaken by health care-related societies, organizations, and collaboratives |
| Be an advocate for families with LEP | Provide resources/tools from federal resources to institutional language access team (examples AHRQ TeamSTEPPS, The Office of Minority Health National Standards on CLAS etc.)29 | Implementation guide to include guidelines on specific setting (ie, children, inpatient setting) | |
| Be willing to tell personal stories about inequities experienced by families with LEP | Provide tools to front -line workers and modify for the local inpatient setting6,30 | Make resources available to hospitals and providers | |
| Strategic discussion between leadership team and language access team at the onset of language implementation plan | Stipulate legal remedies for infractions | ||
| High cost of interpreter services with inadequate, inconsistent reimbursement for language assistance services across payors | Appropriate documentation of interpreter and translator use | Improve awareness about reimbursement under specific institutional context | Develop a financing mechanism for language assistance services across payors focusing on hospitalized patients |
| Adopt and explore a range of strategies to address the economic aspect of linguistic services at each institution | Use reimbursement as an incentive to increase the language access resources | ||
| Share data regarding cost/reimbursement for language assistance services | |||
| Poor/ late identification of families with LEP when hospitalized | Understand the institutional policies to identify patients with LEP | Develop and implement clear policies and procedures on how families with LEP will be identified | Stipulate the use of a standard question to identify families with LEP |
| Ask all caregivers about the preferred language in which they want to receive their medical care | Train and provide resources to front line staff: (1) language identification cards (I speak cards),31 (2) communication devices (VRI/telephonic interpretation), (3) Joint Commission’s Road Map for Hospitals32 | Mandate the identification of preferred language of the parent(s) or guardian for children | |
| Document the need for language assistance services | Standardize electronic health record such that the need for language access is clearly visible to everyone involved in patient care | Develop and disseminate tools for proper identification | |
| Difficulties with timely, reliable language needs in inpatient setting | Know the institutional policies and protocols for obtaining various types of interpreter services | Create standardized workflow on how to access and schedule various types of interpreters | Mandate and fund 24/7 language access services |
| Use services consistently | Provide training for all staff members | Develop effective, timely, and high-quality technology surrounding language needs | |
| Familiarize with the institutional policies regarding how language assistance services are used in local setting | Create policies for prioritizing various type of interpreter services (ie, in-person, VRI, telephone)33 | Increase training and availability of interpreters for rare languages | |
| Advocate for patients when services are not being used | Adjust the availability of services on the basis of common languages used by families at your institution | ||
| Report poor quality/timeliness to supervisors | Periodic monitoring to ensure the delivery of reliable, high-quality, timely services | ||
| Periodic evaluation of current vendors providing the services and availabilities of new vendor | |||
| Poorly defined metrics and quality measures for linguistic care in inpatient setting | Take an active role in defining, measuring and implementing metrics that are meaningful to patients and families | Identify the current language access needs at your local institution | Define and standardize what constitutes an “appropriate use” of interpreter in an inpatient setting in children (ie, every encounter with every provider in a day, once a day encounter, etc) |
| Make improving care for families with LEP a priority at your institution | Identify appropriate metrics to track improvement in hospitalized children | ||
| Develop appropriate measures focused on organizational needs to evaluate performance | Benchmarking metrics for interpreter use for hospitalized children | ||
| Chose SMART aims to improve care for organization with clarity and intention | Increase availability of CAHPS surveys into multiple languages | ||
| Provide easy access to resources/tools through which metrics can be developed | |||
| Review and report internal data consistently and share it widely | |||
| Poor documenting and reporting on interpreter use | Know what information should be documented when using an interpreter service | Standardize policies regarding documentation locally as per state laws | Standardize policies for what information should be documented in the inpatient setting |
| Consistently document the use of interpreters on all medical records | Designate a specific place in the electronic health record in which language access service use can be documented | Report the language services use for families with LEP on national/state data, including CAHPS | |
| Document specific circumstances if language services were not used and what was done to address this (ie, a caregiver who spoke English was at the bedside) | Translate CAHPS survey into various languages using AHRQ translation guideline34 All patient safety events to be reviewed to find out if appropriate language assistance was provided | ||
| Monitoring the data and reviewing it with all stakeholders | |||
| Poor to no training to providers in using language access services | Reinforce trainees on safety and outcomes surrounding patients with LEP | Create a curriculum focused on skillset and available resources for your organization based on policies and language needs in your local area | Develop language needs curriculum to target educational deficit throughout all level of training |
| Teach the skills on how to appropriately use the interpreter services | Work with front-line providers to tailor curriculum | Establish best practices when working with families with LEP during hospitalization | |
| Model appropriate behavior by advocating and using linguistic services while working with trainees | Provide training to all new staff during onboarding/orientation at your institution Provide refreshment training periodically and timely if metrics/protocols have changed Provide implicit bias training at local institutions | ||
| Retain and recruit bilingual providers | Advocate for bilingual providers/staff | Increase the recruitment of both clinical and nonclinical bilingual staff throughout the hospital system (eg, appointment center, registration staff, housekeeping, nurses, and providers) | Provide easy access to language competency training, especially for less-common languages |
| Be a mentor and sponsor | Establish system to document the language proficiency of providers in languages other than English | Increase funding for medical interpreter training | |
| Provide standardized training to bilingual staff/providers if they are willing to serve as medical interpreters for others | Create best practices for health care interpreters Standardize certification requirements for medical interpreters Increase the available certification in multiple languages Create an easy pathway for fluent speakers of non-English languages to get certified | ||
| Time constraints and implicit bias | Be open to learning and willing to build trust with families of LEP by taking the time to ask genuine questions and validating concerns | Redesign institutional policies for physician and ancillary staff (ie, reducing nursing ratios when caring for patients with LEP) | Develop policies for appropriate reimbursement through payers based on time |
| Prepare ahead to schedule a qualified interpreter | Create a standardized workflow for prompt availability of interpreter services at your institution | Develop an innovative, user-friendly telephone/video interpretation system so that services are prompt | |
| Consider using an in-person interpreter as opposed to an audio/video interpreter, if possible, to capture all nonverbal communication | Provide implicit bias training to all providers | Invest and increase the interpreter workforce, including those for rare languages | |
| Advocate for physician-to-patient ratios to be readjusted if there are multiple patients with language assistance needs on your team | |||
| Historical underrepresentation of families with LEP in research studies creating research gaps | Clarify definitions (define LEP, preferred language, type of interpreter, qualification of interpreter) | Prioritize research and internal funding for services for patients with LEP within organization | Increase funding to improve the quality/quantity and rigor of research in linguistic care |
| Prioritize multicenter studies with a focus on cost-benefit ratio of using language assistance services | Allow easy access to databases internally | Large inpatient research database to include details on linguistic service data, including the use and type of services provided | |
| Increase the scientific rigor of the research to address confounding factors like literacy, socioeconomic status, degree of acculturation, etc | |||
| Poor translation services | Familiarize with institutional workflow on how translation services are provided | Evaluate current available translation services with a focus on high-risk areas like discharge documents, including instructions and medications | Create and reinforce translation services for hospitalized children |
| Reinforce providing written documentation at discharge | CAHPS survey to be translated into patient’s preferred language34 | Provide benchmarking for language concordant discharge instructions | |
| Advocate for translation services for patients/families with LEP | Provide easy, efficient, timely translation service | CAHPS survey should include translation services use for patients of LEP families | |
| Access literacy level for parents of hospitalized children | Invest in easy, automated translation services | ||
| Collect information on how translation services are provided and share widely |
| Challenges | Providers | Institutions | Policymakers |
|---|---|---|---|
| Variability in scope and impact of state legislation with only 29 states addressing services exclusively for children, almost none in an inpatient setting26 | Familiarize with legislation at local area of practice | Improve awareness within institution about federal and state specific laws regarding language assistance services | All states to enact regulations, broaden and clarify the federal legislations related to children and hospitalization |
| Familiarize with institutional policies related to care of families with LEP | Inform patients about their rights to access services | Legislation should be focused to address the larger issue of interpreter service and not be limited to specific language/disease/payer | |
| Inconsistent enforcement and implementation of policies | Be aware of the policies and implement them on front lines | Provide clear policies and improve accountability by reinforcing the policies | Consistent reinforcement of the policies undertaken by health care-related societies, organizations, and collaboratives |
| Be an advocate for families with LEP | Provide resources/tools from federal resources to institutional language access team (examples AHRQ TeamSTEPPS, The Office of Minority Health National Standards on CLAS etc.)29 | Implementation guide to include guidelines on specific setting (ie, children, inpatient setting) | |
| Be willing to tell personal stories about inequities experienced by families with LEP | Provide tools to front -line workers and modify for the local inpatient setting6,30 | Make resources available to hospitals and providers | |
| Strategic discussion between leadership team and language access team at the onset of language implementation plan | Stipulate legal remedies for infractions | ||
| High cost of interpreter services with inadequate, inconsistent reimbursement for language assistance services across payors | Appropriate documentation of interpreter and translator use | Improve awareness about reimbursement under specific institutional context | Develop a financing mechanism for language assistance services across payors focusing on hospitalized patients |
| Adopt and explore a range of strategies to address the economic aspect of linguistic services at each institution | Use reimbursement as an incentive to increase the language access resources | ||
| Share data regarding cost/reimbursement for language assistance services | |||
| Poor/ late identification of families with LEP when hospitalized | Understand the institutional policies to identify patients with LEP | Develop and implement clear policies and procedures on how families with LEP will be identified | Stipulate the use of a standard question to identify families with LEP |
| Ask all caregivers about the preferred language in which they want to receive their medical care | Train and provide resources to front line staff: (1) language identification cards (I speak cards),31 (2) communication devices (VRI/telephonic interpretation), (3) Joint Commission’s Road Map for Hospitals32 | Mandate the identification of preferred language of the parent(s) or guardian for children | |
| Document the need for language assistance services | Standardize electronic health record such that the need for language access is clearly visible to everyone involved in patient care | Develop and disseminate tools for proper identification | |
| Difficulties with timely, reliable language needs in inpatient setting | Know the institutional policies and protocols for obtaining various types of interpreter services | Create standardized workflow on how to access and schedule various types of interpreters | Mandate and fund 24/7 language access services |
| Use services consistently | Provide training for all staff members | Develop effective, timely, and high-quality technology surrounding language needs | |
| Familiarize with the institutional policies regarding how language assistance services are used in local setting | Create policies for prioritizing various type of interpreter services (ie, in-person, VRI, telephone)33 | Increase training and availability of interpreters for rare languages | |
| Advocate for patients when services are not being used | Adjust the availability of services on the basis of common languages used by families at your institution | ||
| Report poor quality/timeliness to supervisors | Periodic monitoring to ensure the delivery of reliable, high-quality, timely services | ||
| Periodic evaluation of current vendors providing the services and availabilities of new vendor | |||
| Poorly defined metrics and quality measures for linguistic care in inpatient setting | Take an active role in defining, measuring and implementing metrics that are meaningful to patients and families | Identify the current language access needs at your local institution | Define and standardize what constitutes an “appropriate use” of interpreter in an inpatient setting in children (ie, every encounter with every provider in a day, once a day encounter, etc) |
| Make improving care for families with LEP a priority at your institution | Identify appropriate metrics to track improvement in hospitalized children | ||
| Develop appropriate measures focused on organizational needs to evaluate performance | Benchmarking metrics for interpreter use for hospitalized children | ||
| Chose SMART aims to improve care for organization with clarity and intention | Increase availability of CAHPS surveys into multiple languages | ||
| Provide easy access to resources/tools through which metrics can be developed | |||
| Review and report internal data consistently and share it widely | |||
| Poor documenting and reporting on interpreter use | Know what information should be documented when using an interpreter service | Standardize policies regarding documentation locally as per state laws | Standardize policies for what information should be documented in the inpatient setting |
| Consistently document the use of interpreters on all medical records | Designate a specific place in the electronic health record in which language access service use can be documented | Report the language services use for families with LEP on national/state data, including CAHPS | |
| Document specific circumstances if language services were not used and what was done to address this (ie, a caregiver who spoke English was at the bedside) | Translate CAHPS survey into various languages using AHRQ translation guideline34 All patient safety events to be reviewed to find out if appropriate language assistance was provided | ||
| Monitoring the data and reviewing it with all stakeholders | |||
| Poor to no training to providers in using language access services | Reinforce trainees on safety and outcomes surrounding patients with LEP | Create a curriculum focused on skillset and available resources for your organization based on policies and language needs in your local area | Develop language needs curriculum to target educational deficit throughout all level of training |
| Teach the skills on how to appropriately use the interpreter services | Work with front-line providers to tailor curriculum | Establish best practices when working with families with LEP during hospitalization | |
| Model appropriate behavior by advocating and using linguistic services while working with trainees | Provide training to all new staff during onboarding/orientation at your institution Provide refreshment training periodically and timely if metrics/protocols have changed Provide implicit bias training at local institutions | ||
| Retain and recruit bilingual providers | Advocate for bilingual providers/staff | Increase the recruitment of both clinical and nonclinical bilingual staff throughout the hospital system (eg, appointment center, registration staff, housekeeping, nurses, and providers) | Provide easy access to language competency training, especially for less-common languages |
| Be a mentor and sponsor | Establish system to document the language proficiency of providers in languages other than English | Increase funding for medical interpreter training | |
| Provide standardized training to bilingual staff/providers if they are willing to serve as medical interpreters for others | Create best practices for health care interpreters Standardize certification requirements for medical interpreters Increase the available certification in multiple languages Create an easy pathway for fluent speakers of non-English languages to get certified | ||
| Time constraints and implicit bias | Be open to learning and willing to build trust with families of LEP by taking the time to ask genuine questions and validating concerns | Redesign institutional policies for physician and ancillary staff (ie, reducing nursing ratios when caring for patients with LEP) | Develop policies for appropriate reimbursement through payers based on time |
| Prepare ahead to schedule a qualified interpreter | Create a standardized workflow for prompt availability of interpreter services at your institution | Develop an innovative, user-friendly telephone/video interpretation system so that services are prompt | |
| Consider using an in-person interpreter as opposed to an audio/video interpreter, if possible, to capture all nonverbal communication | Provide implicit bias training to all providers | Invest and increase the interpreter workforce, including those for rare languages | |
| Advocate for physician-to-patient ratios to be readjusted if there are multiple patients with language assistance needs on your team | |||
| Historical underrepresentation of families with LEP in research studies creating research gaps | Clarify definitions (define LEP, preferred language, type of interpreter, qualification of interpreter) | Prioritize research and internal funding for services for patients with LEP within organization | Increase funding to improve the quality/quantity and rigor of research in linguistic care |
| Prioritize multicenter studies with a focus on cost-benefit ratio of using language assistance services | Allow easy access to databases internally | Large inpatient research database to include details on linguistic service data, including the use and type of services provided | |
| Increase the scientific rigor of the research to address confounding factors like literacy, socioeconomic status, degree of acculturation, etc | |||
| Poor translation services | Familiarize with institutional workflow on how translation services are provided | Evaluate current available translation services with a focus on high-risk areas like discharge documents, including instructions and medications | Create and reinforce translation services for hospitalized children |
| Reinforce providing written documentation at discharge | CAHPS survey to be translated into patient’s preferred language34 | Provide benchmarking for language concordant discharge instructions | |
| Advocate for translation services for patients/families with LEP | Provide easy, efficient, timely translation service | CAHPS survey should include translation services use for patients of LEP families | |
| Access literacy level for parents of hospitalized children | Invest in easy, automated translation services | ||
| Collect information on how translation services are provided and share widely |
AHRQ, Agency for Healthcare Research and Quality; CAHPS, Consumer Assessment of Healthcare Providers and Systems; CLAS, culturally and linguistically appropriate services; VRI, video remote interpretation.
Improving the Care of Patients/Families With LEP at an Individual Level
Studies have revealed that a clinician’s choice to use an interpreter service depends on time constraints.11,12 At busy times, physicians are more likely to “get by” without a professional interpreter, which leads to lower quality of care.12,13 Time pressure and stress are known to contribute to implicit bias.14 Implicit bias also leads to “categorization” rather than “individualization.”15 Individualization is when you focus on attributes of a particular patient, as opposed to categorization, when a provider perceives the patient through the filter of his or her group membership (eg, the language they speak or their race). Categorizing leads to dangerous assumptions about religion, culture, and intelligence. When we categorize someone, it becomes easy to devalue and depersonalize them. Physicians need to be open to learning and willing to build trust with language-discordant families. To build trust, one needs to be authentic, ask genuine questions, validate the other person’s concerns, and validate oneself as a health care personnel before assuming their care.16–18 In families with LEP, all these opportunities are minimized or even lost given the time constraints.12 Nonverbal cues, a crucial aspect of communication, are lost when using audio and even video devices.19 Hospitalists are often rushed to find the interpreting devices and then be on hold until an interpreter arrives, and the quality of interpretation may be poor. Even when an in-person interpreter is available at an institution, much time is lost in scheduling the interpreter services. Authenticity and building trust get lost amid focused history taking and treatment plan obligations. A culture of equity can only thrive when providers acknowledge that disparities and bias exist and take responsibility and advocate for the children of families with LEP.
Improving the Care of Patients/Families With LEP at a Microsystem Level
Inpatient linguistic services for children have unique barriers compared with outpatient and adult services. Admissions are usually unplanned, preventing previous interpreter scheduling. Children may have frequent and sudden clinical changes that require extra communication at unexpected times. Surrogate caregivers are the norm in pediatrics, increasing the complexity of communication.
Linguistic services include 2 components: verbal interpretation using an in-person or remote interpreter and translation services, which include providing written materials in patients’ preferred languages.20 Providers require training in developing skillsets on how to use an interpreter and should also be aware of the available resources in their immediate surroundings. Unfortunately, studies have revealed both lack of awareness about resources and a lack of faculty expertise in implementing a curriculum focused on appropriate linguistic care.21,22 Providing written translation documents is often forgotten as a part of linguistic care. Translation documents are not provided consistently, given their unavailability in various languages, mismatched time frames, and inconsistent use.23
Improving the Care of Patients/Families With LEP at a Macrosystem Level
Systems are defined as “invisible fabrics of interrelated actions which often take years to fully play out their effects on each other.”24 The inpatient setting is a rapidly evolving multifaceted system based on acuity, clinical context, local environment, and multidisciplinary involvement. Additionally, hospitalization is a process with a continuum of care involving multiple care providers with various transition points, including admission, transfer of service, and discharge. Various legislation mandates that health care systems provide language access to LEP patients, including Title VI of the 1964 Civil Rights Act, Section 1557 of the Affordable Care Act, Joint Commission standards, and multiple state laws. Despite the legislation, only 10% to 30% of families with LEP receive professional interpreter services.9,25 The presence of varying state laws has created variations in care among states, diseases, languages, payors, clinical settings, and institutions. Many state laws focus primarily on patient education and informed consent; some target specific health care settings, language, and medical conditions.26 The laws vary tremendously in their scope and impact and do not reflect the dynamic nature of the inpatient setting. Similarly, no standards or quality metrics exist to identify and capture language data in an inpatient setting accurately.
Multiple single-center studies have been conducted to improve the care of patients with LEP in the hospital setting22,27 ; however, multicenter studies of hospitalized children of families with LEP are negligible. The lack of clear guidelines has created wide variation within institutions impeding our ability to conduct multicenter trials and quality improvement collaborations.
The United States health care system is globally the most expensive but has poorer outcomes than other industrialized nations. The United States ranked last on performance and health care equity according to the commonwealth fund report, which uses 73 indicators in 5 domains: care process, access, administrative efficiency, equity, and health care outcomes.28 Regardless of how people look, dress, or what language they speak, access to meaningful and equitable health care is every patient’s right, and providing it is every physician’s responsibility. A cultural shift must occur, but an individual or a health care entity alone cannot solve the problem. Individuals, leaders, organizations, medical societies, and associations need to change. Yes, providing linguistic and culturally humble care is daunting, time-consuming, and unfamiliar. However, if we do not take care of this invisible fabric within our health care system, it is only a matter of time before the fabric is frayed to the point of breaking.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
Dr Rajbhandari conceptualized the project, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr Garber contributed to the drafting of the manuscript and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
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