In part two of our series language access in healthcare, Carla Fogaren, a Principal Consultant and Registered Nurse, discusses the importance of language access in healthcare and the impact of Section 1557. She shares the challenges of using machine translation and emphasizes the need for qualified interpreters and translators; along with the importance of testing bilingual clinical staff to ensure their fluency in clinical terminology. This episode shares the with strategies for mitigation for the challenges hospitals and care teams face in implementing language access policies.
In part two of our series language access in healthcare, Carla Fogaren, a Principal Consultant and Registered Nurse, discusses the importance of language access in healthcare and the impact of Section 1557. She shares the challenges of using machine translation and emphasizes the need for qualified interpreters and translators; along with the importance of testing bilingual clinical staff to ensure their fluency in clinical terminology. This episode shares the with strategies for mitigation for the challenges hospitals and care teams face in implementing language access policies.
Learn more about the show: https://www.amnhealthcare.com/campaign/elevate-care-podcast/
Chapters:
00:00 Recap of Part 1
00:28 The Challenges of Machine Translation in Healthcare
03:47 The Importance of Qualified Interpreters and Translators
04:16 Testing Bilingual Clinical Staff for Fluency in Clinical Terminology
08:57 Barriers and Challenges in Implementing Language Access Policies
13:42 Reviewing Clinical Algorithms for Bias in Patient Care
21:06 The Potential of AI in Healthcare Decision-Making
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/
AMN Healthcare Podcasts (00:00.334)
Welcome back to Elevate Care. I'm your host, Kerry Perez, and I'm thrilled to have you join us for part two of our exciting series, The Importance of Language Access in Healthcare with Carla Fogaren. In part one, Carla shared the invaluable insights into the critical role of language access in healthcare and the significant impact of section 1557. If you haven't done so already, give part one a listen and come back to listen to part two. And here's that second portion of the interview.
you the reasons why are endless and you listed so many important things. It sounds like first and foremost, not everyone even just has the trained interpreter to start, right? They're utilizing family. What are maybe the other top two, you know, most important out of this, you know, complete catalog of things that are important? What are the other two biggest maybe changes that enable this access?
Well, one of the things that is very concerning is that, you know, there's the spoken word and then there's the written translation, right? So interpreters interpret spoken word or sign, and then translators might do the translation from one language to another document -wise. A lot of people think that, my, why can't we just use Google Translate or some sort of app to help translate? Well, usually it's only one direction, right? The communication.
And it's actually against the law because it's created so many issues. It doesn't have the sophistication yet. Now, mind you, AI is changing rapidly before us. So perhaps in another two or three years, it will be a lot better. But it doesn't have the sophistication to do medical. Some examples are somebody's cardiac arrested and it came out as your wife's heart was imprisoned.
Okay, there's lots and lots of mistakes that happen and if you think about it, this is life -and -death situations You don't want to miss anything that could be of such a negative impact to that patient So you really are not you're prohibited from using Google Translate and many people do not know that and many people Even though they may know it think that it's benign and it's just people being super super cautious. No, there's real reason for that and the
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Translation, sometimes they'll use machine translation, and that's also prohibited by law. You have to have a qualified translator. So let me rephrase that. It's not prohibited that you can use machine translation to translate medical documents. It's not allowed to be presented to the patient unless a qualified translator reviews it, a human. So let's say that you did this Google translation or whatever.
A medical translator who's qualified and does pretty much only that has to review the document for accuracy before it can be presented to the patient or the public. And this originated very in, think, yeah, but I think it was Virginia or the Carolinas during COVID when they used machine translation and it actually came out on the website that says you do not need to get vaccinated.
So, you know, this, was detrimental to the Hispanic community because they were reading, you do not need to get vaccinated. So that was done with machine translation. So I would say those two things are extremely important. And then the third component, myself being a bilingual clinician, being a Portuguese speaking nurse, you know, is that you have to now make sure that you test your bilingual clinical staff.
as part of section 1557. So by that, mean, let's say you have three Arabic physicians, Arabic speaking physicians. They've been speaking to the Arabic speaking patients all along. Well, you now have to make sure that you have vetted that they clinically fluent to do so. And the law leaves it up to the entity on how we're gonna do it. So in my case, when I started this as the section 1557 coordinator in 2016, you know, we,
tested over 8 ,000 providers. And it was extremely difficult because some of these folks were raised speaking the language. They go to church with their grandmothers in that language, and yet they did not pass this assessment. So they felt inviscinated. They felt like I taking with it cultural identity. And in essence, they are fluent in speaking, conversationally, right? They're fluent, but they're not fluent with the clinical terminology.
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And they really need to be fluent with the clinical terminology. I'll give you an example of a diabetic. There's a test that they do that's called the A1C. It kind of determines how they're doing with the diabetes. Well, if I was to explain to a patient in English about A1C and diabetes, it would probably take me a good five, 10 minutes. If I was to do it in, let's say, Spanish, and I was
fluid in it, but I didn't know all the medical terms. It basically gets rendered like you have too much sugar in your blood. You've got to stay away from sugar. That's not the same level of care that the English speaker got. And you have to always provide the same level of care to all patients, regardless of race, national origin, disability, age, or any of the other factors. So to me, this is a very good thing because out of the eight
thousand that we tested, 40 % of them did not pass. And this was a pretty reasonably easy assessment. It wasn't that difficult. It was difficult enough that I could sleep at night knowing that we did something and I validated their clinical fluency. But 40%, four out of 10 did not pass. And some of the errors that they made were egregious. It was like, you know, one was, we're going to remove
we're going to remove your kidney. And it was like for me, kidney, me. I mean, I don't even know how to do that. I mean, it's just some of the mistakes were really, really bad. Though some of them who failed actually said when they saw the results, okay, I see that now. Others were still really upset and angry that we were not going to allow them to continue to use their language.
under the scope of their license in the clinical practice to care for those patients, right? It would be great if we could have every physician open up their mouth and speak directly to the patient in their language. It would be my dream or a nurse, but it's not gonna happen. It doesn't happen now because we just don't have that kind of distribution geographically of.
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nurses and doctors, they don't even exist, frankly, that speak other languages to the level that we should have, right? So it's to me, it's like if they can do that, then they're putting their hospital system in a much better position to succeed. let's say I pass this assessment, right? Think about this, I'm at the bedside, I'm a nurse and you're Portuguese speaking. I can take care of you without the involvement of an insurer pair. I can care for you myself.
by just speaking to you, doing my nursing, just in a different language. Now let's say that the neurologist walks in to do an assessment and he says, Carla, could you ask her? I am absolutely not able to interpret because I'm not trained as an interpreter. I can do my whole care, but being an interpreter requires all sorts of other skill sets and I'm not trained. So passing this assessment does not give you
the license to be an interpreter. You have to get trained and qualified as an interpreter if you're going to be doing any interpreting. And frankly, doesn't make any sense to take an RN away from their patients to go interpret for someone else. Because who's going to do her clinical duties while she's interpreting? Does that make sense? So I would rather have facilities. Yeah. They can use a phone interpreters or video interpreters if they don't have any staff on site, you know, there's no excuse for anyone.
in my opinion, to not be able to provide language access in the United States with all of the resources that we currently have available. You know, that's a good point because, you know, if it were easy, it would probably be done already. You know, what are maybe some of the barriers or challenges that it poses for hospitals or care teams? And then what are some of maybe the mitigation strategies aside from you have to, it's the law that would make it easier for us to get up and running?
You know, I mean, when you talk to some of these folks at hospitals, know, some of my clients, it's overwhelming. I mean, they're getting all sorts of things from centers for Medicare services, from the estate, from department of public health, everything, right? So it's really hard to stay on top of it. So in my experience, some of the challenges that health care teams may face with any regulation that's specifically with the new section 1557 include things like,
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understanding the compliance requirements, right? The changes may require health care teams to completely update their policies, procedures, and training to ensure compliance. But the worst thing that I find is when somebody is reading something, they don't quite understand it, but they think they do, and they end up doing endless amounts of work in the wrong direction, right? Spending money, time, effort, while they're still not complying because they misinterpreted the compliance requirements.
So, you know, go on some webinars, you know, I'm not trying to sell consulting services. Let me just say that out loud, but get the experts to help you with it, you know, because it's just, it's a lot of nuances and it's usually an area that most people don't understand even today, language access in general. So to have somebody that actually has experience in it, that could be pragmatic, that can put policies and workflows in place.
that actually makes sense for that client, not something that's academic and theoretical, but something that's actually gonna impact that bedside nurse so that he or she knows exactly what to do when presented with a patient who doesn't speak English. The other thing is, it's gonna change discrimination protections, right? I mean, it's gonna have an impact on patient care because many patients experience discrimination. And sometimes it's just unconscious bias.
You know, people don't fully realize it and it's unconscious bias, but they have to be made aware of it. And they also have to be made aware of how to address patients. There's a whole cultural nuance. Being an interpreter is not just about the spoken word from one language to another. It's understanding the culture and being able to be a cultural broker between two oftentimes very different cultures, right? They both wanna help each, they wanna help the patient, but.
Sometimes what's said and how it's said will completely negate any of the treatment plan, because that patient's never gonna trust the provider. Just because of how they were made to feel, right? So an atripetal is much more than just like a black box recording on a plane that just renders boom, boom, boom. Actually, an atripetal may not even do word for word, it's meaning for meaning.
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Right? It's, you know, not word for word because sometimes those words don't exist in the other language. So it's the meaning that they transmit. And then they also make the provider aware of any cultural issues or nuances that they need to know about. And anyway, so it's going to impact patient care, I think, in a very positive way. The implementation of policies and procedures, you know, it's going to be interesting to see how this develops.
Because a lot of hospitals currently, this has been in place for years, this is nothing new, but a lot of hospitals currently don't have policies like on auxiliary aids, on service animals, or even their intrepid services policy is still called something like translation policies, which translation is completely different. So people oftentimes will use interpreter and translator interchangeably.
If you ask me for a translator, provide somebody that could do written translations for you. So you've got to stop by using the right terminology. It's an interpreter or a translator. So these policies are going to be significant changes for some of these organizations, especially around language assistance and discrimination protections. So that's going to take the organization some adjustment, additional resources, and a lot of training. They have to do a lot of training.
You know, because, you know, communication is an illusion in English, right? Sometimes it just doesn't happen. mean, people just don't understand each other. And then there are regulatory agencies like the Joint Commission and DNV that actually accredit hospitals or clinics. And they too have in their regulations specific language about language access and discrimination and patient care and all of that, that need to be followed.
The good news is that Section 1557 and those regulations seem to be much closely aligned so that you don't have to do different things for different things, for different regulations. It's pretty much the same, some specific nuances, but it's not like it's, know, one's telling you to stand on your head and the other one's telling you to stand on your feet. It's very much aligned.
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Do you see that health systems or hospitals will try and get a separate task force to tackle this or with resources being so slim and margins being so slim, are they trying to just squeeze it out of people who have now three different day jobs to put this in order? So that's exactly what happened to me. I have to say, if I got paid for every title I had,
I would have retired a long time ago. So it's like, you know, give it to the busiest person, they'll get it done. So what I would, if in a perfect world, I would say to you, appoint someone at this has been a job, no other job, right? But even then you need to have other people as part of this task force, as you called it. You have to have a section 1557 coordinated by November 2nd of this year appointed.
So I fear that most hospitals are gonna just make their risk manager or their patient advocate or something, the section 1557 compliance coordinator, right? You need to involve your legal and compliance teams because they need to provide guidance on regulatory requirements and ensure that we are adhering to it. Plus when a patient files a complaint, they need to also be involved to make sure that there is an appropriate response to this, right? Clinical teams need to make sure that they
understand the policies, the procedures, and then they incorporate that into the patient care workflows and some decision -making processes that are also part of this. And then on top of it, don't forget the community. You've got to educate the community as well because the more informed the community is, the less opportunity for...
something to fall through the cracks, right? So if the community understands that they have the right to an interpreter, then they would know what to ask for. It's kind of hard to ask for something that you don't know exists at that location. So all of the signage has been hopefully held that. But then with our IT and data people, we would be lost, right? Because an organization should work towards getting their language service provider integrated into the electronic medical record.
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So, like, for instance, AMN has several renditions of integrations into Epic, Meditech, I think Suriname, other companies have that as well, right? But it's so much easier that every time an interpretation is done, it's documented automatically into the electronic medical record. So it helps both the clinician with the burden of having to document more things, and it also helps from a risk and liability perspective, because you have a tracking system of when and what you provide it.
So, you know, that to me is, you know, and don't just do a task force that's going to be like, one and done, because this is going to remain in place. For instance, for translations, you have to provide a list of all its translated documents that you have. And where to find them and in what language. So that changes almost daily because there's a new consent form or new something or other piece of patient discharge information.
You also have to maintain a list of all the qualified bilingual staff that are not interpreting, but just rendering. call it language concordant care. When you render your care under the scope of your practice and license in a different language, because they want to see how you bedded that person. When the joint commission comes in, they might want to see the personnel file and they would like to see, for instance, how do you know that this person's clinically fluent in, you know, Urdu to speak to the patients.
Directly and this is why I always advise any anybody in healthcare. Don't do it yourself. You know, we all time save a penny here or there. They want it to be the one to do it internally all the assessment for providers. And I said, no, because you cannot be neutral and you really need a. Vendor or partner that does only that. And is completely, you know.
It's not subjective thing. They can do a very clear assessment and they can give you the results and it's nothing personal. It's not because I like Dr. Smith more than I like Dr. Windsor. It's completely objective. And then once you get the passing credential, you have to put that in the employee's personnel file because the Joint Commission is going to ask, God forbid there's a legal action or something, you're going to need proof of it.
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And the same thing for doctors, nurses, nurse practitioners, or physician assistants. They need to be kept in the medical staff office. So it's a one time thing. Most hospitals are doing this once. I only did it once the assessment because, you know, doing it every two or three years just doesn't make sense to me. If I passed it clinically today, right, in Portuguese, the assumption would be, if anything, my Portuguese might be better in two years, right? Cause I'm using it more often or whatever.
But even if the provider was born in Portugal, my organization decided that we would test everyone because maybe that provider was born in Portugal. Maybe they went to med school in Portugal. Presumably they have to speak Portuguese fluently clinically. However, they may not have used it here for 12 or 15 years. So we just decided to hold everybody to the same standard. It was a reasonable test, 20 to 30 minutes once.
And then if you pass it to a down, if you weren't, have up to a year, you could take it again in a year because now, you know, what you need to work on. My feeling is that I couldn't teach them how to speak the language, but they could learn the terminology related to the language. The medical terminology. Yeah.
Well, we covered a lot of ground and it is clear that you are definitely an expert in this space. I learned a ton. I'm sure our listeners did. Is there anything else we didn't touch on that you want to leave us with?
I just think that, you another thing is we talked a little bit about clinical decision tools like algorithms, clinical algorithms. We've been using those for years, but a lot of them are driven or by artificial intelligence. And there's specific mention in the law that you really have to evaluate every clinical algorithm that you use to make sure that it's not biased against the things that I mentioned, race, national origin, age, disability, gender, et cetera.
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And I'll give you an example. O2 sat machines, the kind that they put on their fingertip to measure the oxygen level that you have. If I'm brown or black skinned, it's not going to read the levels correctly by five points. So during COVID, that was like a big deal because I could have come into a hospital if I was a brown person at with an 85 % O2 sat rate, but it was right to stream perhaps at
90. And therefore, I mean, excuse me, I would come in with 90, but it was registering at 85, the opposite way, it would not read it correctly. And then I would not receive the COVID protocol. So it would diminish the O2 saturation by three to five points. And that was based on a clinical algorithm. So these clinical algorithms learn from AI, right? So they learn from data from repeated tons of data that they have.
But if you don't have enough data on people of diversity in there for research, for organ transplants, et cetera, it's going to make the same biased mistakes all the time. So it absolutely says that you have to review each and every clinical algorithm to make sure that it's not biased and you have to track them. And then there's a lot of discussion about how AI can help, you know, even with language access. And I firmly believe that it can.
It's just not there yet in my humble opinion as far as interpreting. It can certainly help with like logistical things, et cetera. But as I had mentioned before, you know, it's not just the language, it's knowing how to interpret. When the patient seems to be saying no, but is nodding yes, how is the machine going to be able to interject and say to the provider, I just want to check in with the patient, I need to clarify something.
or if it's a cultural thing, how is the artificial intelligence going to pick up on that once? So I think that, you know, there's great hope for it to be very helpful. But right now I think we need to operate with some guardrails, some safety features. And we have to make sure that for me as a patient, I would want to know when AI is being used in my care plan. For sure. So I would want to know, you know, is the doctor making this decision?
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or is it artificial intelligence? Now, mind you, that being said, there's various studies that show that artificial AI has actually cut up 30 % more breast cancers in radiology mammogram films than the naked eye can. So it's not all bad, right? There's a lot of good that can come out of it, but we have to be very cautious because this is a very critical situation that involves people's lives and we don't wanna make mistakes. And then what are we doing? The AI?
You know, we have to be good stewards of what we're doing. Yeah, completely agree. And I think it's very appropriate to have that, you know, aid in some of the decision tools, but the decision is human. That is, believe, where we're at and very important. Carla, thank you so much. If people want to learn more or get in touch with you, how can they find you?
If they would like to 1 more, I wanted to say 1 more thing. There is going to be an opportunity and this is going to sound very self serving, but is going to be hosting a training for perception 1, 5, 5, 7 coordinators. It's a 3 month program is only 3 modules once a month, but there'll be some whole work in between starting sometime this fall with myself and drew Stevens who's a lawyer that works with us.
So that is something that perhaps they would be interested in. And I would just say to just contact me just Carla dot Fogrin at amnhealthcare .com. That is my consulting email for AMN. And then I make sure that I connect you to the right people if I cannot answer the question. Excellent. Thank you again so much. And to our listeners who hope you.
Learned a lot. certainly did. And we will catch you next time on Elevate Care. Thank you. 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 amnhalfcare .com and follow us on social media to stay updated on new episodes and the ever changing world of health care.