In this first part of a series on language access in healthcare, Kerry interviews Carla Fogaren, a Principal Consultant and Registered Nurse. Carla shares the importance of language access in healthcare and the impact of Section 1557 on language access and disability. From a young age, Carla experienced interpreting for her family in a medical setting and highlights the high demand for qualified interpreters to ensure effective communication and patient understanding. She explains the requirements of Section 1557, including the designation of a coordinator, posting notices of discrimination, establishing policies, and providing auxiliary aids. Carla also discusses the challenges of compliance and the cultural considerations in language access.
In this first part of a series on language access in healthcare, Kerry interviews Carla Fogaren, a Principal Consultant and Registered Nurse. Carla shares the importance of language access in healthcare and the impact of Section 1557 on language access and disability. From a young age, Carla experienced interpreting for her family in a medical setting and highlights the high demand for qualified interpreters to ensure effective communication and patient understanding. She explains the requirements of Section 1557, including the designation of a coordinator, posting notices of discrimination, establishing policies, and providing auxiliary aids. Carla also discusses the challenges of compliance and the cultural considerations in language access.
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Chapters:
00:00 Meet Carla
01:28 Understanding Language Access
09:28 Overview of Section 1557
13:11 Requirements of Section 1557
17:57 Compliance Challenges and Accountability
21:12 The Role of Qualified Interpreters
23:30 Cultural Considerations in Language Access
24:55 Where To Learn More
About Carla:
Carla is a visionary leader in the healthcare industry, known nationally for her pioneering work in medical interpreting, language access, and health disparities. As the System Director of Diversity Initiatives, Interpreter Services, and ADA/504 and Section 1557 Coordinator for Steward Health Care, she oversaw language access services for 42 hospitals and over 600 physician practices in 11 different states.
Carla's impressive career spans over three decades, beginning as a registered nurse in 1988. She was one of twelve individuals who helped to draft the International Medical Interpreters Association (IMIA) Standards of Practice in 1995, a milestone achievement in the field of medical interpreting. Additionally, she was part of an advisory committee for the MA DPH that created the Best Practice Recommendations for hospital-based Interpreter Services in 2001.
Carla's specialized proficiency in conducting mock surveys and gap analyses, with a keen emphasis on Joint Commission and DNV Standards, has consistently steered numerous hospitals towards successful accreditation. Her extensive experience in this domain not only ensures compliance but also enhances operational efficiency and patient care standards. Furthermore, Carla is a distinguished national presenter on topics such as disabilities, diversity, and language access, contributing significantly to the advancement of inclusive healthcare practices nationwide.
In 2003, Carla founded the Forum of the Coordination of Interpreter Services (FOCIS) as a collaborative platform for hospital and clinic-based interpreter programs to share best practices and resources. Originally established as a Massachusetts-based group, FOCIS has since expanded to nationwide membership. She has served as President of FOCIS and President and Vice President of the National Council on Interpreting in Health Care (NCIHC). Carla is also a founding member of Interpreting SAFE-AI Taskforce-Stakeholders- “Advocating for fair and Ethical AI in Interpreting.”
Carla's exceptional leadership has earned her numerous accolades, including the Healthcare Hero award from the Boston Business Journal in 2015. She continues to be a highly sought-after national consultant on language access, health disparities, disabilities, and regulatory requirements for hospitals.
About Kerry:
Kerry Perez leads the design and development of enterprise strategy in addition to overseeing Marketing, Corporate Communications, and Creative Services.
Ms. Perez joined AMN Healthcare in 2007 and has held various roles during her tenure, including recruitment, marketing, innovation, strategy, and M&A. She most recently served as the company’s Vice President of Enterprise Strategy. She also stood up AMN Healthcare's Diligence and Integration Management Office, which led the strategic and functional integration of new acquisitions to drive synergy. She was named among Staffing Industry Analyst’s Top 40 Under 40 in 2001, and she hosts the AMN Healthcare podcast, Elevate Care.
Ms. Perez maintains the guiding principles of being customer obsessed, thinking big and delivering results. She has a passion for mentoring emerging leaders and building effective teams.
Ms. Perez holds a Bachelor of Arts degree in Business Economics and a Bachelor of Arts degree in Communication from the University of California at Santa Barbara. For more than four years, she has served on the board of Dallas-based nonprofit, CitySquare, which focuses on fighting the causes and effects of poverty.
ABOUT THE SHOW
Elevate Care delves into the latest trends, thinking, and best practices shaping the landscape of healthcare. From total talent management to solutions and strategies to expand the reach of care, we discuss methods to enable high quality, flexible workforce and care delivery. We will discuss the latest advancements in technology, the impact of emerging models and settings, physical and virtual, and address strategies to identify and obtain an optimal workforce mix. Tune in to gain valuable insights from thought leaders focused on improving healthcare quality, workforce well-being, and patient outcomes.
Learn more about the show: https://www.amnhealthcare.com/campaign/elevate-care-podcast/
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Welcome to Elevate Care. I'm your host, Keri Perez, and I'm joined here today by Carla Fogarin, who is a principal consultant in the healthcare space as well as a registered nurse. Carla, welcome to the show. Thank you so much for having me. It's a pleasure. Awesome. So tell us a little bit more about you and your expertise. So I've been working in the language access industry and healthcare in general for a very long time. I feel like a fossil in the industry, but
I am a registered nurse and I had the pleasure of overseeing 40 hospitals across the country in 11 states in terms of language access, disabilities, section 1557, which we're here to talk about today, and also diversity and training for very large healthcare system. In addition, we had about 3 ,000 physician practices across those 11 states. So it was...
Right the ride, I may say. So I worked at this facility, this organization for 34 years. And then in May of 2022, I left to become a consultant and I've been consulting on issues, national issues on language access, equity, discrimination, disability, drone commission prep, et cetera, in terms of how it relates to these subjects for the last two years. Excellent.
So important, know, getting back to the basics for maybe some of our viewers who haven't even really heard the term language access before. Can you describe what that means? It might sound, you know, self -explanatory, but a little bit of background there.
Absolutely. For somebody like me, it's, it runs through my blood. Right. So absolutely. And we always get hung up with these acronyms. So if I use any acronyms, you call me out, Carrie, and I will absolutely spell them out. So language access, it used to be called interpreter services and it's still interpreter services. It's specifically related to medical interpreting. So language access is anytime a consumer or client or patient in this case.
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does not speak the same language as the providers or at their facility. So then they in turn have the right to have language access provided to them. And that's usually in terms of an interpreter, whether it's an in -person interpreter via OPI, which is over the phone interpreting, or VRI, which is video remote interpreting. So as you can imagine, there are 6 ,000 languages in the world. There is no way that any hospital, any clinic could be
In the moment, like just rip them out of the pocket, right? With the stethoscope around your neck. It's not going to happen. So we have to rely on not just creating our own pool of trained qualified interpreters, but also relying on partners such as AMN, for instance, and other language service providers to provide us with over the phone interpreting and also video remote interpreters. So this is a fundamental legal right for patients. It's a human right.
Because let's face it without communication, we'd be doing veterinarian here. Right? So, it also includes, obviously, maybe not so obvious. And I want to say that with all due respect, the provision of interpreters for people who are deaf or hard of hearing. So, it's not all about spoken language. It's also about sign language. And it makes it really interesting because.
In the US, we speak English, Australia, New Zealand, Canada, England, a bunch of countries speak English. However, sign language from each of those countries is different than American sign language. So if you have a patient that comes from South Africa where they may speak English and they present at a hospital here in the United States, their sign language is different than American sign language. So you can't just utilize an American sign language to interpret for them.
You have to also then have a certified deaf interpreter who takes the signs and converts them into American Sign Language. And then the American Sign Language interpreter converts it into verbal English. It's amazing. It's really very complex. So it's been a fun experience for me. And I'm obviously very passionate about it because it is such a fundamental right for people to have their own autonomous voice.
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And how did you get started and so passionate about
so I was born and raised, I was born in Angola, Africa, raised in South Africa. And, I immigrated to a city at Colony, Bedford, Massachusetts, which is like little Portugal. was, it's so many Portuguese people. So my background is my parents are Portuguese. so in South Africa, got, you know, to, unfortunately, witnessed a lot of things that were just inequitable in many ways, you know? So I
My mom being a linguist, speaks seven languages. My passion for languages has always existed. But when I immigrated to the United States, after about, we immigrated in 71, 77, my dad died of a brain tumor at the age of 43. And that was my first experience with healthcare in general. And I have to say it
overwhelming, but looking back, it was extremely disappointing what we experienced. And it's funny how when things happen to you, you don't really realize the consequences until sometimes years later. So my dad was in the hospital, he got diagnosed with a brain tumor, we were in the waiting room waiting for the doctors. And when I say we, I mean, my whole family, my Portuguese family is very extended. So it's like the whole busload shows up if anything is going
So the doctor nurse walked into the waiting room and I heard the doctor say, I wonder if anybody here speaks English. My mom who can speak all these languages, including English, could only speak Portuguese. She was so stressed. She could not speak in any other language. She reverted to her mother tongue, her preferred primary language. So at 14, I stepped up and I said, I speak English. And he said, please tell your family that your father has a terminal brain
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So I was focused on, I know these words in Portuguese? It wasn't until my grandmother fell on the ground wailing that I realized, boy, I just delivered literally what was to be his death sentence, because he died three months later. So that did not want me to put on my interpreter cloak and start interpreting galore, but it really...
left a permanent imprint on my soul because my grandmother never looked at me the same way. as he received home care, et cetera, I met a nurse and she was just so inspirational to me that I decided to become a nurse. Full circle later on in life, I'm working at a hospital that is in a large Portuguese community and I was the only Portuguese speaking nurse
So then I became an interpreter. Then I became an interpreter trainer. Then I started the interpreter program and things just went from there. But it was looking back, I think my journey started that day when I had to deliver that news to my family about my dad. Without really knowing that it would impact my life the way it did or steer me in the course of my career the way it did. So for that, I'm very grateful because I'm hoping
You know, maybe other children did not have to experience what I experienced because we had qualified interpreters available. Thank you for sharing. I'm not going to lie. I've got chills right now. haven't spoken about that story before. So that just brings it really to home too about how important this access is and how important it is that everybody has this access, which I know is what we're going to talk about today.
So thank you for setting that groundwork and really humanizing and personalizing what can be probably just, you know, thousands of minutes of phone calls is actually a human moment every single time. So thank you. So I guess, you know, absolutely. And I share it, Carrie, only because of that, because there are too many children in this country that have to grow up too fast and are being put in situations where they don't have the sophistication.
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to be able to tell their parents the diagnoses or ask very intimate questions. And yet they're the only one that has the ability to speak English and providers are not always either doing what they're supposed to be doing or even know how to do it. I'm hoping that it's the latter, that they just don't know how to do it because I don't think anybody would intentionally inflict harm on a child. Right. Yeah, a lot of pressure and that child is also processing things real time as well as you experienced.
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So transitioning is hard to transition from that, but to what we're looking to dive into a little bit more is some of the recent regulations and recent changes in particular, pardon me, with section 1557. Can you give us an overview of what that is, Sure. So I just want to start off with a disclaimer. I am not a lawyer and I don't play one on TV either. So, you know, if you have any
This is not legal advice. anybody listening has any questions about how this is going to impact their program or their entity, please seek guidance from your legal staff that you have. But basically, this podcast did not possibly cover all of the dimensions of Section 1557. But I thought today I would talk to you more about how it impacts language access and disability.
So section one five five seven in very basic terms, prohibits the discrimination on the basis of race, color, national origin, sex, age or disability. And national origin is where the language component comes in. So because I was born in Angola or in Portugal, I speak another language. You cannot discriminate against me because I may not have the level of fluency in English that is required to understand my healthcare. So.
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There's a lot of focus right now on Section 1557. We waited quite a while for the final ruling, and I'll go into a little bit of a background and the history about it. But what I want to make sure that people understand is that Section 1557 is one law that's based on numerous other laws that was built on Title VI of Civil Rights Act of 1964. There's Section 504 of the Rehab Act of 1973.
the ADA Act, the Age Discrimination Act of 1975, as well as the ADA of 1990. All of those laws still remain in effect and have considerable impact and people can be held accountable for it. And then you also have to be aware that you really need to know what the state -specific laws are. So for instance, in Massachusetts, there's a state -specific law on interpretive services in Oregon, in Washington.
Numerous states have specific laws about language access or discrimination, whether it's LGBTQIA, which is also part of Section 1557, but we're not going to address that today, obviously. So it just is a lot of information. And Section 1557 was added to the ACA, the Accountable Care Act in 2010. In 2016, it was reenacted again by President Obama.
In 2020, President Trump pulled some of it back, and then it was just released in April of 2024 by President Biden. To go into effect on July 5th, so it's already in effect, it went into effect on July 5th of 2024. So it's been a long, it's not like it ever went away. It just had like different renditions of
This one is going to be here to stay from what I'm told and what I understand. And it really, in essence of what it relates to language access, it really requires it's lot of new requirements. For instance, you have to designate a Section 1557 coordinator. And that coordinator has specific responsibilities, like answering grievances, documenting grievances, training staff.
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being the go -to person for the system or for the entity on anything to do with Section 1557, which means not just for interpreting or language access, for insurance, for billing, for LGBTQIA, it's for everything that encompasses Section 1557. So imagine being the expert on everything. You just can't be. So this is one of the struggles that organizations are going to have and are having right
The other thing is that they have to post notices of discrimination in prominent places. you know, I don't know if you've been to a hospital lately, Carrie, but it's almost like wallpaper on the hospital now. We've got so much signage, so many posted things, and most of them, unfortunately, while well -intended, are not in the right font size. You have to have it in a size 20 font, just supposed to by ADA standards, be able to read it from three feet away.
And what we find is that we have a bunch of eight and a half by 11s posted to the mall. I mean, you literally need a magnifying glass to go and read anything. So it has to be very visible. It has to be at every point of entry. Also, you have to establish a bunch of new policies if you don't already have it. So you have to have written policies on language access, on non -discrimination, on grievances.
on auxiliary aids, are equipment that can help facilitate communication for patients who are disabled, whether it's a hearing amplifier, where it's an interpreter for like an ASL interpreter, whether it's a TTY phone, whether it's a phone that has the ability to raise the volume. So there's a whole list of auxiliary aids, including things like
magnification for patients who are low vision, the websites have to be appropriate so that screen readers can read them. It's really complex. And after you've got these policies in place, let's say you get the language access policy in place first, the interpreter policy, you have 30 days to start training all of your employees, everyone, and that includes your administration. It includes the senior leadership. It includes
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every healthcare provider, it includes everyone, including legal counsel. And you have to maintain records of that training for at least three years. you know, what's been happening, Carrie, is that Health and Human Services has been, and the Office of Civil Rights has been mandating these things for decades. And providers and organizations have like, well, I didn't know that, you know,
Now they've had it and now they say, now you know it. There's no going back to not knowing. And I need to remind people that Health and Human Services is a law enforcement agency. They're not just like a government agency. They're actually a law enforcement agency. And then a couple more things is, or at least one more thing. They also have to post the notice of availability of language assistance and auxiliary aids.
The signage has to be prominent. The signage for language access has to be in the top 15 languages of that state. And I would really encourage anybody that's listening to this now, ASL will probably never make the top 15 languages of a state, but make that your 16th language. Put the ASL symbol out there on the poster, because in all honesty, those are probably the patients that are most marginalized because they really, really struggle.
it's easier to find somebody that can speak Spanish at a hospital Portuguese or whatever, but to find somebody that's truly, fluent in ASL is really difficult. So at least have the circle so that they can point to it and we'll know who to what rich interpret every require. so those are the bigger changes, including, just, a couple of more, clear definitions on what a qualified interpreter is.
what a qualified translator is and what a qualified bilingual staff person is. So, you know, a lot of work for people to do, but it's a very exciting time in my opinion. Yeah, it sounds very important and even just hearing it almost overwhelming. Before, I know it was a legal requirement and some places were compliant, others weren't. I'm sure it's a whole sort of continuum of who was most compliant and who wasn't.
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Even before this latest act, how many hospitals were fully compliant, would you say, if you had to make a kind of rough estimate? Honestly, I have to tell you that I really had lot of pride in the program that I created, you know, and my former organization. And I would say that we were pretty compliant, but I'm not quite sure that I've ever met a hospital entity that's fully compliant.
fully compliant because you rely on human beings to be fully compliant. Some people will follow the rules and do what they need to do and other people go rogue all the time. I don't think that there is such a thing as being fully compliant in the delivery of this. I think there are hospitals that are fairly very compliant in terms of what they offer. It's the accountability piece that gets a little
It's, how do you hold that doctor accountable when he's choosing to utilize the family members in charter or he hears the bilingual environmental services person go down the corridor who's super nice and bright and then he just pulls them in to interpret, right? You know, risk and compliance people cannot be everywhere to monitor every single patient interaction. So it's really hard to ensure that you're fully compliant.
There are many mechanisms that you put in place with that. You gotta do chart reviews, right, to see if it's documented. Here's another thing, Carrie, in nursing school at least, if it isn't documented, it never happened. And as an expert witness on occasion, if you haven't documented it, it doesn't matter that I know you and that you are the person that follows the rules all the time. If it's not documented, then you utilize an interpreter.
In essence, it's going to be really hard for you to prove that you did. most of these legal actions don't come, don't happen like six months from the incident. It's usually more than a year or two from there. I can barely remember what I did yesterday. Nevermind. You know, I did two years ago with a patient, one of a thousand that I see. Right. So it's really important to make sure that if you're doing the right thing and you should be. Take the moment to put the, intrepid medical,
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ID number in the medical record, you know, and make sure that you don't do any informed consents without a medical interlocutor. If the patient insists on using a family member, and honestly, I told you my story at the beginning of this interview, you know, the reality is many of us have had family members mistreated because of lack of language access.
So they go to the hospital and they treat it as invisible or they need to wait for periods of time that might make clinical sense, but no one explains to the patient why they are waiting. So the assumption is always it's because I don't speak English or they don't like Spanish people or whatever it is. Right. So you have to always have that communication. have to make sure that the patients are aware of what you're doing. And the only way to do that is to have qualified medical interpreters present.
And to make sure that when you're utilizing a qualified medical insurer, you know, you should document it. You should not be using a family member. But if I went with, let's say my mom, and my mom speaks English, but let's say she didn't, and she insisted that I interpret for her, right? Well, it'd be hard for you as an able -speaking provider to know what she's saying to me, right? Because you don't understand Portuguese. However, even if she spoke basic little...
very bits and say, my daughter, Carla, she, she speak for me. Okay. That's not sufficient. You still need to provide an interpreter to let my mom know that you have interpreter services available 24 seven and it's free at no cost to the patient. What would she like to do? She may still choose that she wants me to act as their interpreter, but the law further states that you as the healthcare provider have to determine.
that I have enough fluency in both languages to be able to do a decent job. Now let's face it, how are you going to assess that in three minutes or less? You're not. So I always say, why would you put yourself and that patient at risk? Just utilize the introvert and say to the family member and to the patient, your son, just you're so fortunate that your son is here to help you. We would like him to be your son to ask questions, to take notes, but we have
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qualified trained medical insurgery here that will assist us because the words are going to get a little complicated and can get very medical. And then you and your son can ask all the questions you want. And that's a nice way of honoring the patient's wishes, not disrespecting the family member. But at the same time, you really are protecting that patient because you don't know what the level of fluency
And there's a lot of cultural issues. For instance, I have an aunt that I went to with a, to a colonoscopy once. And she didn't speak any English and this place did not have an interpreter. So I interpreted for her and the doctor was actually excellent. He told us every possible adverse thing that could happen with a colonoscopy, including the fact that she could perforate her bowel and she could, you know, she could die. So when I interpreted that, she looked at me and she said,
why would you bring me to a place like this? I mean, I could die, right? So many family members would actually skip that part of the translation, the interpretation, as you say. And they would just say, they're gonna go in, they're gonna clean it out and look at you and then it will be over. You won't even remember you hadn't done, right? But they won't give her all of the informed information she needs to make an informed decision.
And I don't think that only English speakers warrant that. think every single patient warrants that. Sometimes families out of love will protect their loved ones from cancer diagnosis. In all honesty, I told you that my dad died of a brain tumor, but to the day he died, no one ever told him he had cancer. Because in the Portuguese culture, in many places, that is cruel and unusual to do. You got to always give them faith. Only God can decide when you die.
So the decision was made by family, not my mom, but his two brothers that it would be best if he didn't know. And we checked him for six weeks of chemotherapy, you know, I mean, radiation therapy, excuse me, but it's just, there are certain things it's called protective tooth telling. And there's actually articles and evidence and documents about this. So you got to really make sure that you position yourself to be successful.
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for both you and the patient by utilizing trained qualified introverts. Thank you for joining us today on Elevate Care. If you found this episode valuable, please consider sharing it with a colleague and subscribing to our show on your favorite podcast platform. You can learn more about this episode and our show on our website at amnhelfcare .com and follow us on social media to stay updated on new episodes and the ever -changing world of healthcare.