Language Interpretation/Translation Services

PURPOSE: To provide timely language interpretation services to effectively communicate with all patients with Limited English Proficiency (LEP).

POLICY: Mountains Community Hospital (MCH) provides free interpretation services to patients twenty-four (24) hours a day in a manner consistent with Title VI of the Civil Rights Act of 1964. Title VI of the Civil Rights Act of 1964 states “no person in the United States shall, on the grounds 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.” (42 U.S.C. Section 2000d).

All Hospital employees and physicians providing services at MCH will be responsible to recognize the language assistance needs of patients and to obtain language assistance for all patients with LEP.

PROCEDURE:

Meaningful Access (Four Factor Analysis)

Meaningful Access is free language assistance in accordance with federal guidelines. MCH will update the following four-factor analysis, including but not limited to:

  1. The number of LEP persons eligible to be served or likely to be encountered at MCH.
  2. The frequency with which the LEP persons using a particular language come into contact with MCH.
  3. The nature and importance of MCH’s services/assistance/programs to LEP persons.
  4. MCH’s resources and the cost of providing Meaningful Access. Reasonable steps may cease to be reasonable where the costs imposed exceed the benefits.

The analysis will be reported yearly to CQUIP.

Language Assistance

  1. A person who does not speak English as their primary language and who had limited ability to read, write, speak or understand English may be a LEP person and may be entitled to language assistance services.
  2. Language assistance includes interpretation, which means oral or spoken transfer of a message from one language into another language; and/or translation, which means the written transfer of a message from one language into another language.
  3. MCH staff and physicians shall recognize the language assistance needs of patients and take reasonable steps to provide the opportunity for Meaningful Access to LEP individuals who have difficulty communicating in English.
  4. Way-finding signage is posted throughout the facility.

Translation of Documents

Vital documents that are routinely provided to patients in the English language are also made available in other regularly encountered languages as required by Title VI of the Civil Rights Act of 1964. Administration and department managers are responsible to identify the need of documents for translation. Currently, MCH provides vital documents in Spanish.

  1. All forms that become part of the Medical Record will be sent to the Forms Committee for approval.
  2. Educational materials may be translated as costs allow.

Interpreters

Hospital personnel, family members, or any other individuals are not to be used to interpret.

At all points of contact, written notices and signage will be available for LEP patients. The notices/signs communicate the right to free language assistance services. If the language need of the LEP patient is not listed on the notices/signs CyraCom Client Services is to be contacted by:

  1. Pressing the red button from any “blue phone” or
  2. By calling (800) 481-3289, enter Access #501014014 and enter PIN #9993.

The preferred language of the patient is identified at registration and documented in the Health Information System. The preferred language of each patient is the language in which he/she feels most comfortable in a clinical or nonclinical encounter.

In order to best serve our patients, MCH utilizes the following interpreter services for patients:

  1. Telephone Services – Telephone interpreters are accessible as described below.

Specific instructions are provided in Attachment 1.

  1. CyraCom interpreters are accessed:
  2. By dialing extension 8018 from a Hospital phone, or;
  3. By dialing (800) 481-3293 from any phone and enter Access #501014014 and enter PIN #9993 or;
  4. By the “blue phones” that are placed throughout MCH.
  5. The caller will be prompted for 1) the language; 2) to add a 3rd party caller if necessary; 3) the Medical Record number of the patient 4) PIN number if accessing through (800) 481-3293.
  1. Online Services – Video interpreters are available for American Sign Language (ASL). Instructions for access are described in Attachment 2.
  2. Inbound phone calls for our Spanish speaking patients/clients are made available through (877) 297-2366. The caller will be connected with an interpreter, who will then contact MCH. Access code for incoming Spanish calls is 3936-7390-9617.
  3. Informal interpreters – May include family, friends, employees and other representatives. MCH does not encourage or suggest the use of informal interpreters. A patient may request the use of informal interpreters. However, relying on staff/family/friends frequently leads to misunderstanding, dissatisfaction, omission of vital information, misdiagnosis, inappropriate treatment and lack of compliance.It is the policy of MCH to also use telephone/online interpreters in addition to the informal interpreter. The telephone/online interpreter present ensures accurate interpretation. The use of minor children for interpretation is prohibited. MCH does not conduct formal testing for language competence; therefore, all bilingual staff are considered informal interpreters for the purposes of this policy.

Documentation is to be made in the Health Information System and/or Medical Record for the use of an interpreter(s). Documentation will include the Interpreter Identification Number of the Interpreter used.

For 24-hour assistance call CyraCom Client Services at (800) 481-3289

  1. CyraCom is available for sign language. Processes to access on lap top computer see in Attachment 2.

Monitoring:

This LEP Plan will be reviewed annually. The review will include:

  1. Reports from the Health Information System on the number of patients who are LEP.
  2. Reports from Health Information System and reports from the use of telephone/online services listing the languages used by LEP patients.
  3. A determination of whether 5 percent or 1000 patients speak a specific language, which triggers consideration of document translation needs as a described above.
  4. Analysis of the cost of the interpretation service.

LEP Plan Distribution and Training:

The LEP Plan will be:

  1. Distributed to Administration
  2. Distributed and explained in orientation and in ongoing training sessions for staff
  3. Distributed to Medical Staff
  4. Posted to online Clinical Services Policy and Procedure Manual
  5. Made available upon request

Distribution: Clinical Services Manuals & K Drive

Attachment 1

Accessing an Interpreter via Phone

Blue Phone

  1. Pick up left handset to get a dial tone. (Right handset is for patient)
  2. Press the blue button labeled ACCESS
  3. When prompted, press the white button labeled ACCT/PIN.
  4. Say the language you need, or press “2” for Spanish

Select if you would like to add an additional person to the call.

  1. You can use this option to make outbound calls to a patient with the interpreter on the line with you.
  2. To add an additional person when the session is already in progress, press “8” to be prompted to enter the additional person’s phone number.
  1. When prompted, enter the Medical Record number of the patient
  2. When the interpreter comes on the line, give the interpreter a brief explanation of the call.
  3. Pick up the right handset and pass it to the patient.

Hospital Phone:

  1. Dial extension 8018
  2. Say the language you need, or press “2” for Spanish

Select if you would like to add an additional person on the call

  1. You can use this option to make outbound calls to a patient with the interpreter on the line with you.
  2. To add an additional person when the session is already in progress, press “8” to be prompted to enter the additional person’s phone number.
  1. When prompted, enter the Medical Record number of the patient.
  2. When the interpreter comes on the line, give the interpreter a brief explanation of the call.
  3. Place phone on speaker (if appropriate and does not violate HIPAA).

Any Other Phone

  1. Dial (800) 481-4014
  2. Enter Access #50101-4014
  3. Enter PIN # 9993
  4. Say the language you need, or press “2” for Spanish.

Select if you would like to add an additional person to the call.

  1. You can use this option to make outbound calls to a patient with the interpreter on the line with you.
  2. To add an additional person when the session is already in progress, press “8” to be prompted to enter the additional person’s phone number.
  1. When prompted, enter the Medical Record number of the patient.
  2. When the interpreter comes on the line, give the interpreter a brief explanation of the call.
  3. Place phone on speaker (if appropriate and does not compromise patient confidentiality).

Attachment 2

Accessing an Interpreter Online

AMERICAN SIGN LANGUAGE (ASL)

Available through the Emergency Department, Front Office and the Medical Surgical Units. The Skilled Nursing Facility will be able to access on a case by case basis.

  1. Turn on computer
  2. Click OK on Mountains Community Hospital greeting
  3. User name: mch
  4. Password: WeCare2!
  5. Go to internet
  6. Go to CYRACOM on tool bar
  7. As you start to type the user name, a drop down may appear, click on the drop down and the user name and password will automatically populate
  8. User name:
  9. Password: WeCare2!
  10. Click Sign In
  11. Select American sign language (if not already selected)
  12. Scroll to the bottom and click on Start Session