Hello and welcome to our presentation, A Primer on Communication and Language Assistance. My name is Darci Graves and I am with the Health Determinants and Disparities Practice SRA International, Inc and we help support the work of the HHS Office of Minority Health and their Think Cultural Health initiative.

The Health Determinants and Disparities Practice at SRA International has over 50 years of combined experience in the areas of culturally and linguistically appropriate services, CLAS, health disparities, and health equity

An overview of today.s presentation: we will discuss and cover the importance of effective communication, we will go over concepts and terminology that are important to know, we will review the differences and similarities between interpreters and translators, and we will identify some resources that can help you as you implement communication and language assistance services in your own organization.

So first, Why should we focus on improving communication? This diagram shows us what factors influence communication, and what problems can arise from bad communication. This diagram is adapted from the HHS Agency for Healthcare Research and Quality.

Language, culture, and health literacy levels affect communication between a health professional and a patient. When there are differences in health literacy levels, language abilities, and cultures, it.s likely that communication will suffer.

Communication problems, in turn, can lead to patient safety issues, medical errors, readmissions, and poorer health outcomes. On top of that, poor communication can also cost health systems a lot of money. Now what do we mean by effective communication?

The Joint Commission in their Roadmap for Hospitals defines effective communication as: The successful joint establishment of meaning wherein patients and health care providers exchange information, enabling patients to participate actively in their care from admission through discharge, and ensuring that the responsibilities of both patients and providers are understood. To be truly effective, communication requires a two-way process, both expressive and receptive, in what messages are negotiated until the information is correctly understood by both parties.

I think for our conversation today we can focus on the following: A two-way process in which messages are negotiated until the information is correctly understood by both parties.

The Joint Commission states that successful communication takes place only when providers understand and integrate the information gleaned from their patients, and when patients comprehend accurate, timely, complete, and unambiguous messages from providers in a way that enables them to participate responsibly in their care.

We know all too well some of the grave consequences of ineffective communication. For example, a first responder in Florida misinterpreted a single Spanish word, .intoxicado,. to mean "intoxicated" rather than its intended meaning of "feeling sick to the stomach, or nauseated." This led to a delay in diagnosis, which resulted in a potentially preventable case of quadriplegia, and ultimately, a $71 million malpractice settlement.

Another example is Rita Quintero, a Mexican native who was found wandering the streets of a Kansas town. She seemed to be dressed oddly, seemed not to have bathed recently, and was not able to communicate except for a few Spanish words. She was involuntarily committed and remained hospitalized for 12 years. During her commitment she was treated against her will with psychotropic drugs. It was eventually determined that she was a member of the Tarahumara Indian tribe of Mexico. Her appearance, dress, and behaviors, which had been described as odd and only an indicative of mental illness, were actually traditional aspects of her culture. She had only a limited grasp of Spanish because she was a native speaker of Ramuri, a tribal language. After a Ramuri interpreter was located, she was released and allowed to return to her home.

So, how do we address these issues of ineffective communication and how do we work towards ensuring that the message that we send are the messages received and vice versa. Well there are various concepts to consider before we actually start talking more about the resources that are available.

One of the important concepts to consider is Meaningful Access: Recipients of federal financial assistance are required to take reasonable steps to ensure meaningful access to their programs and activities for their limited English proficient (LEP) persons, and patients, and clients.

The HHS Office of Civil Rights developed a guidance explains that the obligation to provide meaningful access is in fact dependent and starts with an individualized assessment that balances four factors (you may also heard this described as the four factor analysis). To learn more about this four factor analysis, you should visit www.lep.gov.

Another concept that is important to consider is Primary Language which is the language that a limited English proficient individual identifies as the one that he/she uses to communicate effectively and would prefer to use to communicate with service providers.

Plain language is another important concert. Plain language is a strategy for making written and oral information easier to understand; communication that users can understand the first time they read or hear it. A plain language document is one in which people can find what they need, understand what they find, and act appropriately on that understanding. To learn more about plain language you may visit www.plainlanguage.gov.

Another important concept is Health Literacy and health literacy has to do with differences in communication skills of lay people and health professionals, as well as differences in their knowledge of the health topics being discussed. It also has to do with cultural barriers, and sometimes there exists when a language barrier exists as well. It.s important to remember that even highly literate people report difficulty understanding health information.

Someone with limited health literacy may have trouble: Navigating the healthcare system, including filling out complex forms and locating providers and services. The may have trouble sharing personal information, such as health history, with providers. Engaging in self-care and chronic-disease management.

Let.s also keep in mind that all of these concepts health literacy concepts includes numeracy literacy and numeracy skills, which includes the ability to understand numerical and mathematical concepts, like calculations, probability, and risk. This will impact a person.s ability to, for example, calculate blood sugar levels, measure medications, and understand nutrition labels.

You can.t tell someone.s level of health literacy by looking and them or identify their need for plain language, or what their primary language is. But, when you implement culturally and linguistically appropriate services throughout a system, you take into account all of these different concepts and all other communication issues across the board, which helps you bridge those gaps.

So how to we bridge those gaps? We work to degarginaze the system. Language Assistance Services are Mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing.

These services can include in-person interpreters, bilingual staff, or remote interpreting systems such as telephone or video interpreting. Language services also refer to processes in place to provide translation of written materials or signage, sign language, or braille materials.

As we talk about the system, it is important to remember that there are many points of contact that a patient or client goes through as they are trying to negotiate a system.

Communication is important during the patient-provider encounter . but there is so much more to the health and health care continuum. There.s the initial point of contact, how did they learn about you, when did they schedule their appointment, were there forms to complete in order to prepare for their visit, going to registration, waiting in the lobby, billing discussions, pharmacy, all of this before and after the patient provider contact- is all important to remember as we are thinking about communication and we are thinking about language because there are many places where things are being communicated.

So now we are going to move on to talking about interpreters and translators as key parts of this communication and language assistant services.

An interpreter is an individual who renders a message spoken or signed in one language into a second language and who abides by a code of professional ethics. Essentially interpreting is the process of understanding and analyzing a spoken or signed message and reexpressing that message faithfully, accurately, and objectively into another language, taking the cultural and social context into account. The purpose of interpreting is to enable communication between two or more individuals who do not speak one another.s languages.

So, not only is it important that the words are interpreted, but making sure that the meaning is interpreted. So, Concerning or involved with interpreting. Examples are interpreting services and interpreting issues.

In contrast, a translator is an individual who translates written texts or converts a written text into a corresponding written text in a different language. In popular culture we often use interpreter and translator interchangeably, but that is not accurate. They are two different skill sets and they are two different professions.

And so now we are going to talk a little but about how those things come to be, why they do what they do, and further illustrate the differences and the important roles that these professionals play during our health care encounters.

So, why do interpreters and translators participate. Interpreters help make communication possible. Interpreting overcomes language barriers to facilitate understanding. Translating allows individuals who cannot read a specific language to obtain access to written information in their native tongue, which can be oh so important when we are thinking about things like discharge information or consent forms.

Now what? Interpreting is an action. Translation is a product. Interpreting is an action that, once having taken place, is done. Quality interpreting reflects cultural terms, expressions, and idioms that have bearing on the meaning of the content that.s being interpreted. Interpreting must capture any expressions or nuances in meaning to maintain the impact of the original message.

A translation is a product that is permanent and can be shared, stored, reviewed, and revised as often as desired. Quality translating must also reflect cultural terms, expressions, and idioms that have bearing on the meaning of the content. A translation must capture any expression or nuances in meaning and maintain the impact of the original content.

So who are these individuals and how to they work. Interpreters work as part of a triad with the patient and provider. Whereas, A translator often works as a part of a translation team. Interpreters commonly work by themselves as part of a triad with the patient and provider- making up the other parts.

Interpreters must have an advanced level of proficiency in both languages being spoken and must possess exceptional listening and memory skills for accuracy and completeness in verbal expression. Special language aptitude is also required in both the language of medical terminology and in health care systems. Traditionally, interpreters prepare and conduct research prior to the encounter, using resources such as dictionaries and consultation with professionals in a specific field to complete their work.

A translator usually works as a part of a translation team that consists of individuals with advanced levels of proficiency in both languages and with exceptional research skills to ensure the accuracy of their work. Translation teams include proofreaders and editors (and in some cases, desktop publishers, and program managers). All of this again is to ensure that the meaning, not only the words that are moved from one language to another, but the meaning is also conveyed.

And how is this done. Interpreters work .in the moment. whereas translators can work in a different time frame. Interpreters work in the moment and are compelled by the mode of interpreting. Interpreters may consult dictionaries or utilize other resources, but the time between each exchange is only a matter of seconds or minutes.

Interpreters work bidirectionally, going back and forth between two languages. The interpreter functions as a conduit, clarifier, cultural broker, and advocate. Interpreters must be able to perform each role appropriately throughout the encounter.

Interpreters must be sensitive and considerate of both cultures. The goal is to have the listener understand the message as if it were heard directly from the original speaker. Translators on the other hand, work on a different timeframe. They must read an entire text for comprehension before starting the translation, often consulting dictionaries and other resources for correct grammar and terminology.

Most translators usually translate into their native language(s). Translation is a process that requires analysis, conversion, proofreading, and editing. Translators must be sensitive and considerate of both cultures. Localization is a specialized form of translation in which a completely adapted product (translation) takes into consideration differences in culture as well as language, whether that product is software, an Internet site, or a manufactured product. The goal is to produce a translation that appears to have been done originally in the target country.

There are many different forms of interpretation and there are many different forms of translation, and to learn more about this you can consult the National CLAS Standards Blueprint which I will discuss later.

Where does this all take place. Interpreting takes place at a specific time and place, whereas translation can take place at any place, at any time. Interpreters work in public , often for health care interpreters (in a hospital or clinic, for example) or in private (in the case of telephonic and video interpreters who work either from a home office or in a call center).

Interpreters must be present at a specific location; for example, onsite at a hospital or clinic, or at a location that has dedicated resources for telephonic interpreting or video remote interpreting. They must be there as the interaction is taking place.

Translation can take place at any place and any time . only the final product is required to be turned in at a specific place and time. Translators can work in any setting, from the offices of a large translation department to the privacy of their homes.

So, this is s a lot of information and these are only two examples of language services, language access, and language assistance services that are available. So, where can you learn more about these services? The Office of Minority Health has developed a framework for operationalizing CLAS. It.s called the National CLAS Standards. The Standards are an important tool for promoting and implementing culturally and linguistically appropriate services.

The National CLAS Standards were first developed by the HHS Office of Minority Health in 2000. In 2010, the Office of Minority Health launched an enhancement initiative to update the Standards, which incorporated public comment, a literature review, and ongoing consultations with an advisory committee comprised of 36 experts representing a variety of disciplines and organizations.

In April of 2013, we were very excited to released the enhanced National CLAS Standards at the White House. There are 15 Standards, each of which is an action step that guides professionals and organizations in their implementation of culturally and linguistically appropriate services.

The intention of the National CLAS Standards is to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint to health and health care organizations. And actionable ways to address these issues.

The National CLAS Standards are divided into Principle Standard and three themes. The second theme is the one that we have focused on today, Communication and Language Assistance.

Communication and Language Assistance provides guidance on how to effectively meet patients. communication needs, including sign language, braille, oral interpretation, and written translation. The standards in this theme will help organizations comply with federal requirements such as Title VI of the Civil Rights Act of 1964; the Americans with Disabilities Act of 1990; and other relevant federal, state, and local requirements to which they may need to adhere.

The Standards in this theme are as follows: Standard 5 has to do with offering communication and language assistance. It will help organizations make sure that individuals with limited English proficiency and/or other communication needs have equitable access to health services. Standard 5 will also help improve patient safety and reduce medical error related to miscommunication.

Standard 6 has to do with informing individuals of the availability of language assistance services. It will help organizations inform individuals with limited English proficiency, in their preferred language, that language services are readily available at no cost to them. It will also help organizations facilitate access to language services.

If you are interested in more information on communication and language assistance services as well as the National Standards for culturally can linguistically appropriate services in health care, you can visit Think Cultural health at www.thinkculturalhealth.hhs.gov where you can have access to the CLAS Standards, the Blueprint which is a guidance document that lets you, guides you the implementation of the National CLAS Standards, the full title of the Blueprint is A Blueprint for Advancing and Sustaining CLAS Policy and Practice and provides standard by standard instructions and guidance on how to implement the recommendations, how to implement test the compliancy, and how to inform your clients about the communication and language assistance services that you.re going to provide.

So Thank you for listening to today.s Primer on Communication and Language Assistance. We hope that you found it helpful. If you have any questions or if you have any information that you would like to share with us from documents that you created, information that you've gathered, stories you have to tell, please reach out to us at Advancing CLAS@thinkculturalhealth.hhs.gov. Thank you again and have a great day.