Rich Cahill, JD, Vice President and Associate General Counsel, and Susan Shepard, MSN, RN, Senior Director, Patient Safety Education, The Doctors Company

Clear and unambiguous communication constitutes the key component of the physician-patient relationship. Misunderstandings often create frustration and distrust, especially when an adverse event occurs, and can result in professional liability litigation or reports to state medical boards and third-party payers by disgruntled patients and family members. Proactively implementing office procedures to promote optimum communication reduces the risk of disputes.

With our culturally diverse national population language barriers raise the risk for an adverse event. The Department of Health and Human Services (HHS) Revised Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient (LEP) Persons outlines the requirements for recipients of federal financial assistance from HHS to take reasonable steps to ensure LEP persons have access to language services. (These recipients do not include providers who only receive Medicare Part B payments. However, providers that receive funding from any government program such as Medicaid or Medicare Advantage are subject to the requirements.)

To determine the extent of the obligation to provide language assistance, analyze the following four factors:

• The greater the number or proportion of LEP persons served or encountered by your clinic, the more likely language services will be needed.
• Even if unpredictable or infrequent, there must be a plan for providing language assistance for LEP persons.
• Determine whether a delay in accessing your services could have serious or life-threatening implications.
• Consider the resources available and the cost to provide them. As a solo practitioner, you are not expected to provide the same level of service as a large, multispecialty group. Investigate technological services or sharing resources with other providers.

Avoid using family members as interpreters. Lay personnel rarely understand medical terminology. A patient may not want a family member to hear private medical information.

Only adults should serve as interpreters if a family member must be used—unless no one is available, and urgent action is needed. Consider training a clinical staff member to do translations or contacting a certified interpreter services. Other resources include your local hospital, the patient's health plan, the Registry of Interpreters for the Deaf, or the local center for the deaf. Also, keep consent forms—especially for invasive procedures—translated into the applicable non-English languages by a certified translator.

The Agency for Healthcare Research and Quality (AHRQ) has prepared a guide, Improving Patient Safety Systems for Patients With Limited English Proficiency, which recommends that practices focus on the following:

• Understanding medication instructions is complicated for all patients, but even more difficult for LEP patients. Both patients and providers need to communicate accurately about mode of administration, allergies, and side effects.
• Obtaining informed consent remains a hallmark of patient safety and a critical medical and legal responsibility. Achieving informed consent for LEP patients may require extra effort, but LEP patients should not be excluded from learning about choices that might affect their health and well-being.
• Understanding discharge instructions is especially challenging for LEP patients. Speaking Together: National Language Services Network, a project funded by the Robert Wood Johnson Foundation, which created the Speaking Together Toolkit, found the need for greater use of interpreters at key moments of information exchange, such as at assessment and discharge—not just during the acute phase of treatment.

Relatively simple communication tools can provide some helpful solutions. These include:

• AskMe3™: Rx for Patient Safety: Ask Me 3
• The teach-back method: AHRQ: Use the Teach-Back Method: Tool #5
• The SHARE approach: AHRQ: The SHARE Approach—Using the Teach-Back Technique: A Reference Guide for Health Care Providers
• Patient experience surveys: The Doctors Company: Patient Experience Surveys

To help minimize patient harm resulting from their LEP, develop and implement a plan for language access in your practice. For more information, see the Centers for Medicare and Medicaid Services' Guide to Developing a Language Access Plan.