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Workshop D-3: using bilingual employees effectively: qualifications, training, and management issuesPeer-to-peer practice advancement sessionThe goal of peer-to-peer practice advancement sessions is to allow professional peers the opportunity to discuss, before an audience, issues of common concern as a way of advancing the state of practice in their respective fields. These two-hour sessions will have 5-7 featured experts who will be led in a discussion of key issues related to the theme of the session. Speakers will not make formal presentations, but instead provide critical details of their programs to each other and to the audience in 2-page handouts. During the session, each expert will concisely address specific questions or topics developed and distributed in advance before engaging in a moderated discussion with each other. The last half hour will be reserved for audience Q&A This session will focus on issues related to training, using, and managing bilingual employees (BE) who function as interpreters while holding down other jobs in a health care organization. The discussion will evolve from the following stage-setting questions:
The participants for this session are: Marjory Bancroft Director, Cross Cultural Communications, Ellicott City, Maryland Lou Hampers, MD, MBA, Medical Director, Emergency Department, The Children’s Hospital, Denver, Colorado Javier González Director of Language Initiatives, Center for Immigrant Health, NYU School of Medicine, New York, New York Barbara Rayes Maricopa County Medical Interpreter Project, Phoenix, Arizona Beatriz M Solís, MPH Director, Cultural and Linguistic Services, L.A. Care Health Plan, Los Angeles, California Moderator: Participant abstracts and bios can be found on the pages that follow.
Marjory A. Bancroft, MA, Director, Cross-Cultural Communications, Ellicott City, Maryland For LEP patients, equal access to health care is impossible without trained interpreters. Most large health organizations use bilingual employees to interpret, though interpreter trainings are aimed primarily at professional interpreters. This dichotomy is unwieldy and unwise. Who interprets in health care settings? Language access is not always (or typically) mediated by contract or staff interpreters but more often by bilingual employees who interpret. These bilingual employees may be clerical workers, receptionists, clinicians or custodial staff, among others. Most receive no interpreter training, and when they do it fails to meet their needs. Marjory Bancroft, MA, and Lourdes Rubio, MA, LPC, have created The Community Interpreter: the only 40-hour interpreter curriculum in the U.S. that specifically addresses in depth and detail the needs of bilingual employees who interpret. This program supports employees in health care, education and community services (e.g. domestic violence centers, refugee resettlement, senior housing, homeless shelters, etc.) who are proficient in two languages and already interpreting in the field. The five-day curriculum introduces participants to professional ethics, skills and standards of practice for interpreters, showing bilingual employees how they can adapt these ethics and standards to their workplace. Cross-Cultural Communications is a team of trainers and consultants specialized in overcoming language barriers in health and human services. Three to four trainers are assigned to each 40-hour training. Program Success Participants who attend The Community Interpreter program feel validated and report that they have learned practical skills that meet their needs. The needs of dual role interpreters are distinct in many ways from those of contract or staff interpreters. Whether the question is one of ethics, interpreter roles or standards of practice, after the encounter the professional interpreter walks away. The bilingual employee cannot walk away. These part-time interpreters who play a crucial role in health care face challenges that are often not discussed by the health care interpreting field. As a result, participants who complete the program have developed the skills they need to:
Challenges and Solutions Challenge Challenge Challenge
Challenge Challenge Challenge Lessons Learned While Training Bilingual Employees to Interpret
Marjory Bancroft is the founder and Director of Cross-Cultural Communications in Maryland. An immigrant from Canada, she has lived in eight countries and speaks five languages. She holds a BA and MA in linguistics from Université Laval in Quebec City as well as certificates in advanced Arabic, German and Spanish philology from Jordan, Germany and Spain. With over 25 years experience in language training and language access, she has worked for universities, health institutions, state and local government and national, regional and local nonprofits. A former translator and bilingual employee interpreter, she directed a community language bank of 200 interpreters and translators and established a health program for low-income immigrants and refugees. She has led dozens of community interpreter and cultural competence trainings for health and community services and performs research and technical assistance in the field. Recently she authored an environmental scan of interpreter standards of practice for the National Council on Interpreting in Health Care.
Lou Hampers, MD, MBA, Medical Director, Emergency Department, The Children’s Hospital, Denver, CO In the spring of 2003 The Children’s Hospital (TCH) formed the Language Advisory Committee (LAC). This committee included representatives from many different facets of our large institution: medical interpreters, physicians, nurses, respiratory therapists, admissions, human resources and corporate compliance staff. The LAC produced a report whose purpose was to assess and develop strategies to minimize the language barrier for Limited English Proficient (LEP) patients and families at TCH. This report recommended best use of bilingual staff resources, outside of the Medical Interpreters Department, for the delivery of linguistically appropriate services as a part of patient care. This effort is part of a hospital initiative on cultural diversity – addressing how we as an organization promote respect for and understanding of all people – the patients and their families who come here for healthcare and our own workforce. How well we communicate with our customers affects every aspect of patient care – from scheduling appointments to offering help in wayfinding to explaining treatment – from simple directions on how to take medicine to consoling families in difficult, emotional situations. Over the course of the last year, the committee reviewed current interpreter and translator practices at TCH, the regulatory compliance requirements of the CLAS (Culturally and Linguistically Appropriate Services) Standards, and surveyed interested parties (patients and their families, providers, bilingual staff used as ad hoc interpreters, clinical coordinators and nursing managers); we also compared our practices with other institutions (using BENCH and Press-Ganey data, as well as metro Denver hospital data). We read literature on the subject, authored by TCH providers and nationally known experts – so we understood the ramifications for not providing the highest of quality services. Indeed, patient safety is the primary reason for this effort. TCH is lucky to have a workforce of many talented and bilingual staff, who are dedicated to their patients and families, and who speak a wide assortment of languages besides English. Spanish is by far the language most widely spoken by our LEP patients and families. Many of our bilingual staff speak second languages fluently, while others have a limited grasp of secondary languages. The LAC’s recommendation for improving the use of these internal resources includes having bilingual employees take a competency test of their language skills (Denver agency TranslationLinks to provide this testing). This will address the CLAS standard requiring us to prove the competency of our interpreter staff. The Human Resources and Medical Interpreters departments will oversee our new program which will identify, train, and reward these Qualified Bilingual Staff. The LAC presents the following recommendation: increase patient safety and satisfaction by establishing Qualified Bilingual Staff program to supplement our professional Medical Interpreters Department and contracted telephone interpreting services. To accomplish this:
Anticipated outcomes include:
The LAC seeks approval for these recommendations which will improve the translation and interpretation services for our TCH patients and families.
Dr. Hampers is the Medical Director of the Emergency Department of The Children’s Hospital of Denver and is an Assistant Professor of Pediatrics at the University of Colorado. His previous work on language barriers and emergency department resource utilization was funded by the Ambulatory Pediatric Association, and received the Willis Wingert Best Paper Prize from the American Academy of Pediatrics in 1998. He also served on the project expert panel for the study of the impact of language barriers on health care costs and quality, sponsored by the Office of Minority Health. He currently serves as co-chair of the Ambulatory Pediatric Association Special Interest Group on Culture, Ethnicity and Health Care. His research has focused on the cost-effectiveness of professional interpreters and foreign language instruction for physicians. He is currently investigating the efficacy of telephonic medical interpretation in a randomized trial funded by The Children’s Hospital Research Institute.
Javier González, BA Director, Language Initiatives, Center for Immigrant Health, NYU School of Medicine, New York, New York The Center for Immigrant Health (CIH) [formerly the New York Task Force on Immigrant Health] was created in 1989 as a result of a groundbreaking conference on immigrant health issues. It is a coalition of health care providers, health service researchers, administrators, policy makers, and community members and advocates. The Center is part of the Division of Primary Care Internal Medicine of New York University School of Medicine. The Center’s mission is to facilitate the delivery of linguistically, culturally, and epidemiologically sensitive health care services to newcomer populations. The Center strives for the elimination of ethnic and racial disparities in health care. The Center's activities include health promotion and education, applied research and evaluation projects, policy advocacy, and cultural competence and interpreter and translator training. The Center now includes a network of over 1,000 public health and medical professionals and immigrant community advocates. In response to the language barrier to accessing services in New York City, the Center conducted an analysis of language access strategies across the country. In the Fall of 1995, site visits were conducted in California (Los Angeles, Oakland, San Diego, San Francisco), Illinois (Chicago), Massachusetts (Boston, Worcester), and Minnesota (Minneapolis/St. Paul). Following the nationwide review, the Center initiated a Language Needs Assessment of New York City health care facilities. The following factors were assessed: linguistic service needs of patients; position of hospital administration with regard to language services; current strategies used to address language needs of patients; organization of language services within health care facility structure; methods of screening and training interpreters (if any); and methods of financing. Because of the assessment results, the Center for Immigrant Health developed the Language Initiatives Program to innovate various language access strategies, including, but not limited to, the following:
Training History, including bilingual personnel from health care facilities The Center has a long history of providing quality training in the language field for healthcare. The only such program in the New York City area, CIH has trained over 1,000 individuals in medical interpreting, and has a nascent but growing course in medical translation. Trained individuals have included ‘mainly’ medical and non-medical staff of various titles (including physicians, nurses, physician assistants, etc.) who provide interpreting services on a regular basis but are untrained. CIH also trains bilingual volunteers at healthcare facilities; bilingual legally blind individuals; and bilingual individuals from the general public. One of the highlights of the training methodology imparted by the Center according to hospital personnel, who have benefited from it, is the Center’s flexible and pragmatic approach to medical interpreting. As the debate escalates on whether the medical interpreter should be solely a conduit of linguistic messages or an active cultural broker, the CIH’s training methodology emphasizes the importance of an approach that while recognizing that it is the role of the medical provider to elicit and negotiate cultural differences directly with the patient through the voice of the interpreter, also takes into consideration the complexities that exist in multicultural centers of health, where the practice of ad hoc interpreting continues to be prevalent. To this effect, the Center has conducted numerous trainings in proximal interpreting where the role of the medical interpreter is more proactive and whose visibility presupposes a more active role regarding cultural and advocacy issues confronted by patients with limited English proficiency, including, but not limited to, immigrants as well as refugees.
Furthermore, as the Center continues to showcase its national recognized, award-winning program in remote simultaneous medical interpreting, recognition and demand for training utilizing the conduit model vis-à-vis simultaneous interpreting escalate. In response to the success of this project and envisioning the potential it lends to their clients’ employment opportunities, the New York State Commission for the Blind and Visually Handicapped, as well as Helen Keller Services for the Blind, and the Jewish Guild for the Blind, continue to call on the Center for training in medical interpreting Challenges and Lessons Learned
Javier González is Director of Language Initiatives for the Center for Immigrant Health. As such, he has worked to develop curricula in the areas of interpreting and translating in healthcare, including screening, testing and evaluation, training, and standards. He worked to implement the Remote Simultaneous Medical Interpretation (RSMI) project, developed a simultaneous medical interpreting training curriculum and quality control program, and created the Center's translation service. He is also an active participant in groundbreaking research in the nascent field of medical interpreting and has created educational videos. Javier is ardently leading programs at the Center for Immigrant Health to facilitate the delivery of linguistically appropriate health services for immigrants and refugees in New York and elsewhere. Javier has a B.A. in Anthropology from George Washington University.
Barbara Rayes, BA, Co-Director, Maricopa County Medical Interpreter Project and Spanish Translator, Phoenix Children’s Hospital, Phoenix, Arizona The Maricopa County Medical Interpreter Project (MCMIP) originally was funded by St. Luke’s Health Initiatives with a 3-year grant for $213,000 to improve communication between health care providers and patients with limited English proficiency in hospital settings in greater Phoenix, Arizona. A unique collaboration between the state medical school, the children’s hospital and an inclusive task force/working group, the project has exceeded the original goals and was successful in leveraging the original grant for more than $450,000 of additional funding and $300,000 of in-kind contribution from the collaborators. The percentage of Arizona’s population who speak Spanish is nearly double the national average of 10.8 percent, with Phoenix and Tucson outpacing most other cities nationwide at roughly 28 percent. In Maricopa County, Spanish is the language spoken at home for 938,220 people. Ranked fourth behind Texas, New Mexico and California in the percentage of residents five and older who speak Spanish at home, Arizona has a tremendous need for skilled bilingual interpreters in Arizona hospitals, where accurate, clear communication can literally mean the difference between life and death. Accomplishments in 3 years
Lessons Learned People who interpret seek support. The overwhelming response to MCMIP training and networking opportunities is an indication of how much interpreters need to connect with each other. Each MCMIP class was filled to capacity and several meetings were at “standing room only” levels of participation. Dual-role and dedicated staff interpreters benefit from each other when they train and network together. Dual-role interpreters often use the Spanish Bilingual Assistant program as a pathway into medical school, nursing school, and other university programs. Some have advanced into management. Training dual-role and dedicated staff interpreters together has also made limit-setting easier. When a student sees what quality interpretation looks like, they often look for ways to start declining assignments that they know are beyond their abilities.
The focus of medical interpreter training in Arizona has changed. The Spanish Bilingual Assistant program used to be a course in anatomy and physiology in English and Spanish. Now, the focus is on interpreting medical information, which better meets the needs of health care providers and patients. The Spanish Bilingual Assistant program now consists of:
Students learn techniques for working with patients and families of other cultures. Interpreter practice is integrated into anatomy and physiology lessons throughout the sixty-hour program. The ethics component has been expanded to reflect national work toward consensus on a code of ethics and standards of practice. Colleges and hospitals make a great team. Working translators and interpreters contribute expertise in applied interpretation and applied translation; University of Arizona and Arizona State University contribute theoretical linguistic foundations for the work being done. The result is the introduction of a community-based program into medical and linguistic curriculae in Arizona’s colleges and universities. It takes good work and hard work. By bringing together the collective expertise and power of caring leaders across competing healthcare systems, MCMIP is meeting the needs of management, providers and patients around the issue of safe communication. This has enabled us to create a unique position in our rapidly growing and increasingly complicated healthcare marketplace. MCMIP Values
Barbara Rayes served as the Co-Director for the Maricopa County Medical Interpreter Project, a three-year grant-funded partnership between the University of Arizona and Phoenix Children’s Hospital. The focus of her role was to write instructional objectives, develop training materials, and teach. She currently works as a Spanish translator at Phoenix Children’s Hospital. Irma Bustamante brought years of experience in policy and institutionalizing interpreter services. She trained administrators in culturally and linguistically appropriate services in health care settings and currently coordinates language and cultural services at Phoenix Children’s Hospital. Nita Francis initiated the grant and coordinated the project. She organized people, secured additional funding, and brought together hospitals and health care organizations in a landmark effort to improve the quality of care for speakers of languages other than English.
Beatriz M Solís, MPH Director, Cultural and Linguistic Services Department, L.A. Care Health Plan, Los Angeles, California L. A. Care Health Plan is a public, not-for-profit health plan serving Los Angeles County since 1997. L.A. Care is one of California’s largest health plans and the nation’s largest publicly governed health plan. Currently, more than 740,000 children and adults are L.A. Care members, and they receive health care coverage through Medicaid managed care, Healthy Families (California’s S-CHIP), and the Healthy Kids Programs. Fifty-one percent of our member population prefers to speak a language other than English, and over 35 languages are spoken by our members. As such, meeting their language needs is an on-going challenge that is further complicated by a managed care environment, consisting of complex contracting arrangements with commercial HMOs, safety net providers, and county clinics. Two years ago, L.A. Care Health Plan developed a 40-hour health care interpreter training for bilingual providers and staff who work as interpreters in diverse health care settings. Support for this training program was provided by The California Endowment. The training program is provided at no-cost to health care providers and staff within our provider network. For added convenience to trainees, the training is mobile, and can be taken to any clinic, hospital, or community-based organization during the week and on weekends. The training program was approved for 40 contact hours of continuing medical education (CME) and continuing education units (CEUs). To date we have trained over 203 individuals representing over 25 different clinics and hospitals in Los Angeles County. The training was designed to be held in five sessions of eight hours each. Each session focuses on a specific theme, allowing trainees to gradually advance from basic to more complex subjects. At each session trainees are required to complete a pre-test and a post-test, which assess whether key learning objectives were met, and determine if they “graduate” from the course. Although only 6% of the attendees have failed thus far, this presentation will also discuss the challenges of attrition, failing scores, and language proficiency (in either English or the target language). In addition, this presentation will highlight the demographic characteristics of the trainees. We also will discuss how geomapping software is used to show the areas covered by the training. For example, we have mapped the clinics that have been represented in our trainings, and overlayed that information with the linguistic needs of our membership. The presentation will also discuss evaluation findings, which have led to the development of several tools to assist the trainees increase their language skills. For instance, originally, our project intended to only produce the participant manual in English-Spanish; however, the manual is now available in Los Angeles County’s 9 non-English threshold languages (i.e., Armenian, Chinese, Farsi, Khmer (Cambodian), Korean, Russian, Spanish, Tagalog, and Vietnamese). For example, to address the linguistic needs of our membership and to capitalize on the bilingual skills of participants enrolled in our health care interpreter trainings, 36 pages of the manual were translated (including dialogues, anatomy charts, and medical terminology exercises). Moreover, the presentation will discuss lessons learned in the “marketing” approach of our training programs that aim to build momentum and interest in increasing skills of a diverse work force. Beatriz Solís, MPH, is Director of Cultural and Linguistic Services for L.A. Care Health Plan, the largest Medicaid plan in the country. Beatriz developed the first department dedicated to address cultural and linguistic issues in a managed care setting. Prior to her work at L.A. Care, she was a research associate and project manager with the Center for Health Policy Research at UCLA. Beatriz is currently a doctoral student in the School of Public Health at UCLA, where she also earned her master's degree. She has focused her research efforts on: HIV/AIDs and the impact of this disease on women of color; Latina sexual health; access to health care coverage for low-income women; and welfare reform. She also serves as a board member to the California Pan Ethnic Health Network and a council member to the California State Department of Health Services, Department of Women’s Health.
Facilitator:
M. Jean Gilbert Ph.D. (University of California, Santa Barbara) is a medical anthropologist with a specialization in social epidemiology and prevention research. Her initial studies in California and Mexico examined family structure and familial relationships in the two countries. Further research examined cross-cultural similarities and differences in health care utilization and support networks among couples having their first babies. She was Scholar in Latino Alcohol Studies at the University of California, Los Angeles from 1984 to 1990 and a member of the Epidemiology and Prevention Study Group, National Institute of Alcohol Abuse and Alcoholism, from 1986 to 1990. She served on the National Research Council, Institute of Medicine Committee on Alcoholism Prevention Research in 1989-1991 and as a consultant to the National Institute on Drug Abuse and the Agency for Health Care Policy and Research. From 1993-2000 she was the Director of Cultural Competence for Kaiser Permanente California where she collaborated in the design of cultural competency curricula for health care professionals and provided expert consulting in the structuring of service delivery to special populations. She was series editor for Kaiser Permanente’s physician handbooks on delivering culturally competent care to specific groups. She also collaborated in the creation of physician training modules that included the design and production of video vignettes showing physician/patient cross-cultural clinic encounters. Dr. Gilbert has served on the Cultural and Linguistics Task Force for MediCal Managed Care, chairing the Linguistics Committee, as well as on the Department of Health and Human Services National Advisory Committee for Culturally and Linguistically Appropriate Health Services (CLAS). She currently serves on the Cultural and Linguistic Advisory Group for LA Care, and the Los Angeles County Cultural and Linguistic Standards Workgroup. She was a founding member of the California Healthcare Interpreters Association (CHIA). She has consulted with the Nathan Kline Psychiatric Institute in New York on standards for assessing cultural responsiveness in the care of mental health patients and advises the White Memorial Medical Center, Los Angeles, on cultural and linguistic issues in Family Practice Residency training. In 2002 she was appointed to the National Advisory Committee of Hablamos Juntos, a major initiative focused on interpretation in healthcare sponsored by the Robert Wood Johnson Foundation. In 2002, she chaired the project, “Principles and Recommended Standards for Cultural Competence Education of Healthcare Professionals” sponsored by The California Endowment. Recently she, along with Thomas Lonner and Cindy Roat, completed a research project entitled “Training Dual-Role Interpreters: Costs and Benefits” that looked at the practice of using bilingual medical assistants as interpreters in a community clinic obstetrical setting. A Visiting Professor in Anthropology at California State University, Long Beach, Dr. Gilbert teaches clinical and applied anthropology. Through her consulting business, “Cultures in the Clinic,” she advises health care organizations, lectures and conducts workshops for health care professionals.
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National Conference is presented by State University of New York Downstate Medical Center, Resources for Cross Cultural Health Care, Arthur Ashe Institute for Urban Health, US Department of Health and Human Services, Joint Commission on Accreditation of Healthcare Organizations |
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| As with the rest of Diversity Rx, this section
is a work in progress and we welcome information on other efforts, programs,
and reports that will expand upon the information offered here. Please
let us know if you have other examples to include here. |
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