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High-quality interpreting is key to advancing health equity

REUTERS/Regis Duvignau
Linguistic diversity has become ingrained in the fabric of U.S. health care.

In February of this year, the Minnesota Department of Health published its 14th annual Adverse Health Events report, a list of preventable yet serious clinical events that can result in harm to patients. The root cause analysis showed that communication issues accounted for approximately 20 percent of all reported events. Although the report does not include individual data such as ethnicity or language spoken by patients, few would disagree that patients with limited English proficiency (LEP) are at a higher risk for receiving suboptimal care. In such cases, the quality of interpreting is a key factor for overcoming challenges posed by the language barrier.

According to the U.S. Census, more than 225,000 Minnesotans have limited English fluency and rely on interpreters to communicate with their health providers. The National Healthcare Quality and Disparities Report shows that ethnic minorities and LEP patients are more likely to receive lower quality care and have poorer health outcomes. But providing highly qualified interpreters helps ensure that they receive the level care comparable to that of English speakers.

However, medical interpreting, unlike other health care professions, has been largely left out of regulatory oversight. Minnesota has no statewide qualification standards for interpreting in health care and there is, therefore, no way to ensure minimum quality and safety levels for LEP patients across the board.

Variation in qualification levels

To fill this regulatory vacuum, health care organizations have each been setting their own standards for their staff interpreters. However, most interpreters in Minnesota contract their services with agencies and are not rigorously screened for meeting certain training, education or language proficiency standards. This has resulted in a variation in qualification levels among interpreters and can lead to inconsistencies in care quality for LEP patients.

In 2009, Minnesota established a statewide roster for spoken language health care interpreters. Interpreters pay a $50 annual fee to be on the roster, but do not need to meet any requirements to be listed, and the information they provide is never verified by the Minnesota Department of Health. In addition, since 2011, interpreters must be listed on the roster to receive reimbursement from Medical Assistance and MinnesotaCare.

According to the Minnesota Department of Human Services (unpublished raw data), in 2017 Minnesota paid over $44.5M on interpreter services for LEP patients enrolled in Minnesota Health Care Plans in both fee-for-service and managed care. This is a large amount of public dollars to spend on services without a guarantee of minimum quality and safety in return.

Legislative proposals in 2015 and 2017 attempted to establish a registry with higher qualification requirements and failed. The proposals met opposition and were not passed, amid community fears that requiring higher standards could result in some interpreters leaving the field and potentially reducing access to interpreter services in certain language groups.

How to improve access to qualified interpreters

Nevertheless, Minnesota can improve access to qualified health care interpreters. This can be done by listing interpreter qualifications on the current roster. Interpreters can voluntarily list their training, experience or certifications credentials on the application form. These would later be verified and displayed on the roster. Roster fees, which are currently not being used, can cover the costs of the initial technical upgrade and for ongoing maintenance of the roster.

This solution would not reduce the number of interpreters available, since they would all continue to be listed on the roster. Yet at the same time, displaying interpreter qualifications would create the transparency that health care organizations and providers need to provide access to the best possible interpreters for their patients.

Enhancing the current roster is an incremental step toward improving quality of care for LEP speakers. Future actions to continue advancing interpreter standards can include establishing a statewide complaint reporting and resolution process, creating affordable training and education options for interpreters, or adding patient language for adverse health events reporting, to name a few.

Linguistic diversity has become ingrained in the fabric of U.S. health care. The lack of oversight of the quality of care our taxpayer money pays for, and the risk of human harm are too large to ignore. Minnesota already has some of the largest disparities in health quality. If we are to eliminate them we need to begin closing the health gaps one by one, including the language gap for Limited English Proficient speakers. It is in the best interest of every Minnesotan to have a healthy state, and health begins with good communication and equitable access to quality and safe care for all.

Elma Johnson is a master's in public health student at the University of Minnesota. She has worked at Hennepin County Medical Center for the past 13 years as a medical interpreter and was the supervisor of its Interpreter Services department from 2012 through 2016. She lives in Minneapolis.

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Comments (3)

Very interesting, however, I

Very interesting, however, I would say that the real reason the bill didn’t pass in 2014 was because there is a group of agencies that was opposed to it, so they paid a lobbyist and “convinced” interpreters and legislators that it was not a good idea... now these are the agencies that don’t care if their interpreters are qualified or not.
In 2016 A House Representative pulled the bill because a big group of interpreters (from his district) were in opposition, and this senator was up for re-election in Nov., my guess is that the number of votes were more important then healthcare equaty.

I disagree with the idea of just adding your credentials to the roaster and then have MDH verify them... I rather have the $ that we pay go to better oversight such as background checks and follow up on complaints.

Other Minorities

This is a great article! As a certified Arabic interpreter we feel our profession has not been appreciated. I also like to note that we have to include other ethnic minorities with LEP. The US census which many studies and research depends upon does not include the Arabic as an example, no funding, no research to include in our conversation.

Look to Norway

As a native of North Dakota who has lived in Norway since 1974, I've seen both healthcare systems at work first- hand. In Norway, I work as a translator and interpreter, although not in the hospital sector. That being said, I've been following along with the development of the hospital interpreting services at Norway's largest hospital, the Oslo University Hospital, since its inception in 2013-14. Oslo has a large immigrant population and that one hospital alone placed orders for about 15,000 assignments per year in 2014. As far as I can tell, the new interpreting service has been a huge success. It is administrated by individuals who are themselves qualified interpreters, and I'm convinced that lives have been saved thanks to good interpreters. The service has premises on the hospital grounds that include small rooms equipped with computer systems and screens to allow the interpreters to work remotely, providing quality interpreting services at a distance to other places in Norway where there may be no qualified interpreter available in Swahili or Mandarin, etc. They also provide in-house training and terminology lists and, not least, a system for quality control of the services provided.

Norway's Directorate of Integration and Diversity (IMDi) established a 5-tiered system, the Norwegian National Register of Interpreters in 2009, see https://www.tolkeportalen.no/no/Systemsider/The-Norwegian-National-Regis.... The register is used actively by many, but sadly not all, public bodies. The register is publicly available, and the hospital interpreting service can tap into it very conveniently. It takes time to build up a system like this, but it strikes me that it can't be necessary for every state or every country to re-invent the wheel. I know the administrators of the system at Oslo University Hospital have spoken at a number of conferences. Perhaps it's time for Minnesota to look for Norway for a few good ideas on this topic? The system here isn't perfect, but it's far better than having unqualified individuals pay USD 50 to get on a list that is basically a crap shoot for those whose lives they may or may not be endangering.