How Five Health Systems are Improving their Language … · · 2017-03-12• Final rule little...

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Beryl Institute Patient Experience Conference 2017

How Five Health Systems are Improving their Language Access Programs to Address the New ACA Regulation

Joe Valenzuela, Baylor Scott & White

Helen Scarr, UHealth

Kathleen To, Swedish Medical Center

Paula Harsin, Banner Health System

Dr. Sunita Mishra, Providence

MODERATOR: David B. Hunt, J.D., Critical Measures

Panelists:

• National experts on health equity, cross-cultural healthcare and the law of language access.

• Selected by the American Hospital Association and Institute for Diversity in Health Management as national consultant to #123forEquity Program.

• Created nation’s first e-learning program on The Law of Language Access in Healthcare (2010).

• Conducted national webinars on the law of language access in health care for the ABA and the AHA.

• Selected by BCBSA in 2013 as its national vendor for cultural competence training and consulting services.

• National and international presentations on The New Science of Unconscious Bias including keynote presentations for the American Medical Association.

Moderator

About Critical Measures

David B. Hunt, J.D.CRITICAL MEASURES, President and CEO

Beryl Institute Patient Experience Conference 2017 3

Presentation Objectives

• Define new language access regulations affecting LEP and Deaf and Hard of Hearing patients under Section 1557 of the Affordable Care Act.

• Identify how leading organizations are addressing the challenges of implementing the new ACA regulations.

• Identify the appropriate use of traditional interpreting methods coupled with innovative technology to support stricter guidelines implemented by the ACA.

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AGENDA

1. Welcome and Introductions

2. Overview of Federal Language Access Laws

3. New Section 1557 ACA Regulations

4. How Five Leading Health Organizations Are Adapting to the New Section 1557 ACA Regs

5. Questions and Answers

6. Adjourn

Beryl Institute Patient Experience Conference 2017Sponsored by InDemand Interpreting

Overview of Federal Language Access Laws


• Prevents federal money from being used to support programs that discriminate on the basis of race, color or national origin.

• Providers covered by Title VI if they receive federal funds (Medicare, Medicaid, etc.) Exception: Medicare Part B clinics

• Requires providers to take “reasonable steps” to provide “meaningful access” to federal health programs.

• U.S. citizenship not required. (“Persons” vs citizens)

• Failure to provide free language access to LEP regarded as national origin discrimination. Lau v. Nichols, (U.S. 1974)

• No private right to sue for language access violations. (Alexander v. Sandoval, (U.S. 2001, Scalia)

• Right to select method of language assistance belongs to M.D.

Title VI of the Civil Rights Act of 1964

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Americans With Disabilities Act (ADA)

• Section 504 of the Rehabilitation Act of 1973 requires recipients of federal financial aid to be equally accessible to handicapped persons. Duty to ensure “effective communication” if 15+ ees.

• Titles II and III of the Americans with Disabilities Act prohibit discrimination against persons with disabilities in places of public accommodation. (No employer size limit.)

• Both of these laws harmonized by the ADA Amendments Act (ADAAA,2008).

• Exceptions: must accommodate unless “undue burden” or “fundamental alteration of program”. (Note: Fogari decision)

• Private cause of action allowed (unlike Title VI).

• Legal duty extends beyond patient.

• Providers have discretion but “primary consideration” should be given to patient’s preferred method of accommodation. (Title II standard is higher than Title III)

Beryl Institute Patient Experience Conference 2017Sponsored by InDemand Interpreting

Overview of the New, ACA Section 1557 Language Access Regulations


Section 1557 of the Affordable Care Act (ACA)

• Section 1557 of the ACA prohibits discrimination on the basis of race, color, national origin, sex, disability and age by:

– Any health program/activity that receives federal funding

• First federal civil rights law to prohibit sex discrimination in health care. (Impacts pregnancy, sexual orientation and gender identity and expression )

• Excludes Medicare Part B providers. No employer size restriction.

• Final rule little different from proposed rule in content.

• Gives LEP private right to sue under ACA (not Title VI). Rumble v. Fairview (DC MN 2015)

• Creates major changes in the law of language access

• Effective date: July 18, 2016. (Except for health plans…January 1, 2017)

• Enforcement by DHHS Office of Civil Rights (OCR) not DOJ

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Enforcement of the New ACA Regulations

• Enforcement mechanisms under Title VI, Title IX, the Age Act and Section 504 apply to violations of Section 1557

• Enforcement agency: OCR (not DOJ). OCR authorized to conduct compliance reviews and complaint investigations as well as to provide technical assistance and guidance. OCR may consider conducting unannounced onsite compliance reviews

• Covered entities required to keep records, submit compliance reports to OCR, name a designated official to be responsible for compliance.

• Noncompliance could result in suspension of, termination or refusal to grant or continue Federal financial assistance or a referral to DOJ with recommendation to bring legal proceedings.

• Private right of action and compensatory damages are available for violations of Section 1557 regulations. Note applicability of Civil Rights Attorney’s Fees Act of 1976.

• Violations by one hospital in a system may occasion remedial action by the entire system.


“Qualified Interpreter” DEFINED

• The new ACA regulations represent a shift from requiring “competent” interpreters to requiring “qualified” interpreters. Under the final ACA regulations a “qualified” interpreter is defined as:

– An individual who adheres to interpreter ethics and client confidentiality requirements, and who, via a remote interpreting service or in-person appearance,

– Has demonstrated language proficiency and the ability to interpret effectively, accurately and impartially including specialized medical terminology

• Presumably, to be a “qualified” interpreter, one must first have gone through some qualification process.

• “Above-average familiarity with speaking or understanding a language other than English does not suffice…”


The Bottom Line

• By moving the legal standard from “competent” interpreters to “qualified” interpreters, DHHS is increasing the standard of care and legal duty owed to LEP and Deaf and Hard of Hearing patients.

• Providers will bear the financial burden of increasing the professionalism of their language access services.

• Healthcare organizations must now pressure physicians and nurses to actually use “qualified” interpreters instead of untrained family members and friends, minor children and bilingual staff.

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• The use of minor children as medical interpreters

• The use of adult family members and friends as medical interpreters

• The use of bilingual staff without formal training as medical interpreters

Final ACA Regs Specifically Restrict:


EXCEPTION: “Minor children may only be

used as medical interpreters in an

emergency involving an imminent threat to

the safety or welfare of an individual or the

public where no qualified interpreter is

immediately available.”

Restrictions On Minor Children as Medical Interpreters


Providers may not use adult family members or friends as medical interpreters unless:

1. There is an emergency involving an imminent threat to the safety or welfare of the LEP patient where no qualified interpreter is immediately available, or

2. Where the LEP patient specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide such assistance and reliance on that adult for assistance is appropriate under the circumstances …

Restrictions on the Use of Adult Family Members & Friends as Medical Interpreters

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RULE: Providers shall not rely on staff other than qualified bilingual/multilingual staff to communicate directly with LEP patients.

Restrictions On the Use Of Untrained Bilingual Staff as Medical Interpreters

Definition of bilingual/multilingual staff: A member of the provider’s workforce who is designated to provide oral language assistance as part of the individual’s current, assigned job responsibilities and who has demonstrated that he or she:

1) is proficient in speaking and understanding both spoken English and at least one other spoken language, including any necessary specialized vocabulary, terminology and phraseology, and

2) is able to effectively, accurately, and impartially communicate directly with LEP patients in their primary languages.


What If the ACA is Repealed?• First, the need to use qualified medical interpreters has always centered more on

improving patient quality and safety than it has on regulatory compliance.

• Second, for the sake of argument, let’s say that the ACA is repealed. Even if that is the case, other federal language access laws (Title VI, the ADA) will still remain on the books. In addition, repealing the ACA would not change the caselaw requirements (i.e. court decisions) that require the use of interpreters during informed consent discussions. Finally, repealing the ACA at the federal level does not change many of the progressive state law requirements that providers use qualified medical interpreters. To the extent that these other federal and state laws remain on the books, “freezing” meaningful progress on language access issues only increases providers’ prospective liability.

• Third, repealing the ACA does not change what we know to be national best practices regarding the use of qualified medical interpreters. Institutions who aspire to be leaders will continue to follow these national best practices.

• Fourth, repealing the ACA does nothing to change the underlying competitive or market forces that are increasingly forcing providers to use qualified medical interpreters. (i.e. the LEP population will only continue to grow, become better educated and become more of a force politically; in addition, in many metropolitan areas, hospital systems are actively competing for patients and market share on the basis of language access.)


Baylor University Medical Center at Dallas

Joe Valenzuela, MBADirector of Support Services

Dallas, TX

Overview of Presentation

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• Joe Valenzuela is the Director of Support Services for BaylorUniversity Medical Center (BUMC) at Dallas. He received aB.S. in Clinical Service Management from Texas Tech HealthSciences Center and also has an executive M.B.A. from TexasWoman’s University.

• He oversees the daily operations for Patient Relations,Volunteer, International and Interpretive Services for a 952licensed bed hospital located in Dallas, Texas.

• With 16 years of healthcare experience and along with hispatient advocacy work, Joe has helped to improve patientrights, as well as the language access program at BUMC toensure every patient’s voice is heard.

Joe ValenzuelaBaylor University Medical Center at Dallas, Director of Support Services

Language Access Program

• Over-the phone interpretation– Dual handset phones on every

nursing unit– Employee badges for easy access

• Written document translation• Test & train bilingual staff• Onsite interpretations

(staff & vendor)• Video Remote Interpreting (VRI)

– 2014 – implemented as 1st Baylor facility - 15 additional sites added

– Working towards having VRI devices on each nursing unit

– 20+ languages available including Spanish & American Sign Language

– Voice-over phone capabilities


Challenges • No Corporate structure for Language Access

• Electronic Medical Record Limitations– No fields for Nursing & Physician documentation of usage

• Staff education– Over 5,000 employees to reach w/new requirements

• Reduced onsite interpretive staff due to budgetary restrictions

• Patients not initially receptive to VRI devices especially deaf or hard of hearing patients

• Varied costs associated w/language services

• Improved Compliance = Additional Expenses

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Best Practices• Created specific fields in

Electronic Medical Record• Developed a Limited English

Proficient Report• Audit patient records for

quality assurance and re-education opportunities

• Recently completed RFP to identify language access vendors Baylor could partner with to improve language access at each facility – Employee testing and training– Updated contracts to include

tiered pricing for minute usage


Language Access Services

Helen L. Scarr, MHSA

Developing a Health System’s Language Access Program


• Helen Scarr, MHSA, Executive Director, Patient Advocacy and Experience for UHealth – Master of Health Services Administration – Bachelor of Social Work – UHealth for 21+ years

• Consistent Focus: Remains patient advocacy and optimizing the patient experience (through various title changes)

• 2012: UM Mailman Center for Child Development– A University Center of Excellence in Developmental Disabilities

(UCEDD)– Family Faculty and Community Liaison (Added Responsibility)

• 2013 - Assumed responsibility for developing and managing UHealth Language Access Services for LEP patients and patients with disabilities

• Developing Portfolio of Language Access Services (LAS)

Helen ScarrUHealth – the University of Miami Health System, Executive Director, Patient Advocacy and Experience

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Language Access Services (LAS) Portfolio

• LEP (Limited English Proficienct) Policy (2009, 2014, 2016…)

• Bilingual Staff and Patient Family

• In Person Interpretation – Contract Interpreters

• (In Person Interpretation – Staff Interpreters) – NEVER HAD

• Over the Phone (OPI) Interpretation

• VRI (Video Remote Interpreting) New - 2016

• Voice Over IP New - 2016

• Qualified Bilingual Staff New - 2015

• Continue to explore other LAS best practices

Beryl Institute Patient Experience Conference 2017 26InDemandInterpreting.com

VRI –Most Significant Addition to the UHealth LAS Portfolio


VRI Platforms

• Carts

– Envy

– Essential

• iPads

• iPhonesLaunched Feb 2017

• Through the EMR –InDemand Clarity ConnectExploring

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Challenges to VRI Rollout

• Unfunded mandate

• Administrative silos; complicated billing/accounting

• Competing incentives across the system

• No corporate comprehensive approach to LAS

• No Language and Cultural Services Department

• No staff interpreters

• Easier to “grab a bilingual employee” or “use Google”

• Wi-Fi optimization variability in multiple locations

• Audiology Booths

Beryl Institute Patient Experience Conference 2017 29InDemandInterpreting.com

Pushing the Boundaries…


Innovative Uses of VRI

• Pediatric Mobile Clinic

• Debbie School – Inclusive education, with Auditory Program

– Often parents and staff don’t speak the same language

– IEPs and other parent conversations

• On practitioner iPhones – immediacy and compliant

• Video Conference – Surprised and delighted a teenage patient with JRA, when we conferenced with Mailman Center employee, who is an adult with JRA

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Next Steps:• Push for health system level LAS budgeting and operations

• Draw from best practices of colleagues on the panel and at other health systems

– Awareness

– Policy/Procedures

– Qualifying bilingual staff

• Campaign to increase VRI adoption by faculty and staff

• Work with In Demand to market VRI to targeted populations to increase market share


Kathleen To,System Manager, SHS

Seattle, WA

Effective Communication Support at Swedish Health Services


Healthcare: • Developed and manage the language services and ADA communication

services at Swedish Health Services, a 5-hospital, 7 campus system• Member of Somali Health BoardEducation:• Provided ESL & VESL to refugee and immigrants• Taught diverse, low-income parents parenting skills, immigration rights,

parent leadership skills, and literacy skills• Taught ABE and GED classes to prisoners Target Population: • Worked in refugee camp and provided refugee resettlement services in

multiple states• Provided social services to New Arrivals and immigrants, from Head Start

& K-12 children, families, teens to Senior Services• Provided training to local agencies and schools on providing Culturally and

Linguistically Appropriate services to diverse families, and immigration issues

Received degrees and completed coursework at University of Illinois, University of Michigan and University of Washington

Kathleen ToSwedish Health Services System Manager

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Provision of Language Access Services at Swedish Health Services

• In person interpretation (foreign & sign language) provided by seven agencies and 22 staff interpreters.

• VRI provided-21 video languages; 280 carts system-wide

• Telephonic interpretation, 200+ languages

• Translation of patient vital documents into top 8-10 languages

• Specialty services-CART, Braille, Assistive Devices, Hearing Induction Loops, VRS, Document Magnifier Screen Readers


Challenges to Implementation of Effective Language Support Services

• Cost $$$$$ - in times of declining reimbursements, unfunded mandates are difficult

• Staff education (constant turnover) & adherence to standards-”convenience” of using ad hoc interpreters (Communication is a patient safety issue!)

• Infrastructure issues (wi-fi connectivity, phones in exam rooms, etc.)• Limited number of video languages; need for rare or hard to serve

languages• Sheer volume of translations needed; access and availability issues• Changing demographics vs. interpreter capacity (& competition with

other local healthcare organizations)• Sign language interpreter capacity • ACA 1557 validates the policies, standards and training we’ve been

implementing – it give it “teeth”!


SHS Communication “Wins”

• Strong staff interpreter program that provides interpretation (in-person & VRI), translation and

training

• Great support from organization leadership- they get it!

• New documentation of patient sensory loss in EMRto raise awareness and give support

• Swedish Medical Group clinics just added assistive devices to all of their locations to better support patients with sensory loss

• Bilingual staff policy which restricts staff from acting as an interpreter and using their bilingual skills until they have been “qualified” by an outside agency through testing.

• Good community and agency collaborations to support effective communication (SAIL, WASCLA, HLAA, etc.)

• Robust sensory assessment, assistive device & VRIsupport for patients and visitors

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Paula Harsin, Senior ManagerCorporate Language and Cultural Services

Our goal: to provide consistently effective communication for

our patients with language barriers


• Paula has been with Banner Health for 11 years working in the areas of language access and cultural services, as well as patient education and health literacy.

• She started by creating an interpretation program for a 120-bed Banner hospital that they grew into a regional position supporting 9 critical access hospitals to meet Banner policies from their rural locations in 5 states.

• Currently oversees system-wide language access program working to standardize processes across the organization for quality patient communication and care.

Paula HarsinBanner Health, Senior Manager, Corporate Language and Cultural Services


Banner Health – Our Organization

• Based in Phoenix, AZ with facilities in six other Western states

• Includes 28 Hospitals, 36 urgent care clinics, 200+ physician clinics, ambulatory and home-based services, and University of Arizona medical facilities

• Facilities range from critical access rural hospitals to 650+ bed acute care to academia, and all aspects of ambulatory care

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Banner’s Language Access Program

• Centralized Corporate Language and Cultural Services department including an Interpreter Educator and a Translation Manager

• OPI and VRI in all locations (500+ VRI devices)

• Staff Spanish interpreters in five hospitals

• Contracted outside interpreter services to augment VRI and OPI where they will not provide an effective means of communication


Recent Challenges

Prior to ACA 1557, Banner undertook:

• System-wide interpretation redesign to better meet the needs of our deaf and hard of hearing patients

• New detailed deaf policy that describes sign language services using both VRI and contracted interpreters to provide effective communication

• Required major expansion of VRI (43O+ new devices) deployed over three months, as well as additional auxiliary aids and video relay phones


A Unique Feature of our Program

Banner Spanish Language Assistants Program

• Assessment and training program (40 – 64 hr) for bilingual Spanish staff

• Participants are certified as Banner Spanish Language Assistants (BSLAs) but not as Qualified Interpreters.

• BSLAs interpret in a limited role as defined in our Qualified Interpreters policy, and do not replace staff interpreters, VRI or OPI.

• Program includes a bilingual provider assessment administered by a contracted agency.

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Sunita Mishra MD, MBA,Medical Director of Innovation

Seattle, WA

Consumer Innovation at Providence St. Joseph Health


• Sunita Mishra, MD is the Medical Director of Innovation at PSJH.She has focused on consumer innovation to improve patientexperience and access.

• She is the chief clinician over Express Care services at PSJH andhas worked with the Digital Innovation Group and ProvidenceVentures to develop a digital platform to improve patientengagement and outcomes.

• She studied medicine at the University of Arizona, andcompleted Internal Medicine training at the University ofWashington. She holds an MBA from the Wharton School,University of Pennsylvania.

Sunita Mishra Providence St. Joseph Health, Medical Director of Innovation


VRI in Retail clinics

• InDemand monitors installed to provide VRI in all 33 retail clinics as part of the tech stack of the Express Care service line.

• Wide adoption of the technology by providers in these sites with a sustainable and consistent workflow.

• This technology and service has been vital for patient satisfaction and provider engagement.

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Q&A | Thank You

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