••Fall 2006/Vol. 10, No. 3

CCC Update

By Gayle Tang, MSN, RN; Oscar Lanza; Fátima M Rodríguez, MPH; Annie Chang

"The directions on the bottle of blood-pressure pills read simply enough: 'Take once a day until finished.' But a Mexican immigrant still wobbly in her English, misreads just one word. In her native Spanish, 'once,' means 11. The pills, if taken too many at a time, make her dizzy--or worse. They could kill her."¹

The lack of comprehensible and usable written and spoken language is a major barrier to health communication targeting primary and secondary disease prevention and is a major contributor to the misuse of health care, patient noncompliance, and rising health care costs.² Without appropriate and quality language services, limited-English proficient (LEP) and non-English proficient (NEP) patients experience compromised health care--often relying upon "safety-net" public and nonprofit providers, and using alternative or underground sources of care.³

At Kaiser Permanente (KP), we have an opportunity and an obligation to improve the health and quality of life of our members. KP's membership is a microcosm of the diversity of our nation and our world, representing over 100 different languages. For members whose primary or preferred language is other than English, our ability to provide patient-centered care is often challenged when we cannot communicate effectively in their languages. For example, how do we manage informed consent? How do we ensure that LEP/NEP patients have correct and complete information to follow pre-operative instructions as well as access to medical benefits and coverage information? The availability of qualified interpreters and comprehensible written in-language material is thus paramount to ensuring equal access to health information and crucial for treatment adherence, patient safety, and quality care.

Current State of Translations

Our current systems are in a state of chaos when it comes to translating written materials. KP, as with other health care organizations, is overwhelmed by the task to provide high-quality translations for members while maximizing efficiency and containing costs. Mounting pressure from federal and state regulations and mandates pertaining to cultural and linguistic services (ie, Title VI of the Civil Rights Act,^a Culturally and Linguistically Appropriate Services (CLAS) Standards,^b and state-specific cultural and linguistic regulations) has created an urgency to translate member-informing materials for our linguistically diverse membership. Yet, little or no guidance is offered from legislative and accreditation agencies to help health care delivery systems comply with regulatory requirements.² Additionally, there are no established health care industry standards for ensuring quality translations. Thus, the reaction throughout the industry has been to translate materials immediately and arbitrarily.

A myriad of processes and systems exists among different health care organizations, and even within KP. Variations in translation protocol can be found at all levels of operation: regional, facility, and departmental. The translation of materials often ranges from asking a "bilingual" staff person or family member at hand to hiring independent contractors with varying degrees of health care and translation expertise. Therefore, the accuracy, literacy level, cultural appropriateness, and other components of in-language materials are often unpredictable. In some languages, health care concepts and terminology used in the US do not exist, creating the need for commitment and resources to standardize approaches for meaningful and appropriate translations. Table 1 illustrates some errors in translations, which contribute to consumer confusion.

Programwide Assessment

As part of a Programwide initiative to ensure quality translation and equal access to in-language materials, in 2005, National Diversity's National Linguistic & Cultural Programs (NLCP) implemented a survey to examine how providers and staff accessed translated materials at the department and facility levels. NLCP directed this survey to providers and staff Programwide,^c who reflect diverse cross-functional groups and work with translated materials in various capacities. The survey was developed as a Web-based tool that was completed and returned through an online survey provider.

Survey Findings

Survey data showed that little has been formally documented at KP about its translation work (ie, supply, utilization, and processes), particularly since the responsibility of translating materials has been left to facilities and/or departments. Furthermore, translations usually are done in arbitrary, at-hand, or quick-fix means due to the lack of translation infrastructure, systems, and protocols.

Survey respondents identified various challenges, including:

• · Lack of knowledge on how to access translated materials.
• · Lack of departmental and/or facilitywide budgets to translate materials.
• · Lack of organizational structure in general to share and access materials.
• · Questionable quality of available translated information.
• · Significant delays in getting translations completed.
• · Materials in Spanish and Chinese are limited, and other language materials are more sparse.

Additionally, many survey respondents expressed frustration and a sense of powerlessness in dealing with translations. A few respondents shared that:

"Employees have to spend hours trying to find the right contact for something that is outside of their daily routine."

"It is difficult to find excellence in translation service, as there are often a multitude of errors in translation."

Furthermore, the NLCP Translation Survey found that providers and staff desired guidance and resources to obtain high-quality and cost-effective translations for their patients. They offered various solutions to begin addressing the challenges faced. Many stated that KP should:

• · Adopt a centralized process for translations that is organized on a regional or national level.
• · Build a system that would increase access to existing available language materials. Specifically, create a document repository or clearinghouse of translated materials.
• · Develop a standard, formal procedure for coordinating the translations process.
• · Establish a pool of KP-approved translation vendors that meet various business requirements (ie, cost, quality, efficiency)
• · Standardize key documents such as consent forms, member letters, etc, to minimize the number of documents to be translated.

The survey findings shed light on the Programwide operational reality that translations are often being duplicated within each region, facility, and even department because there is little or no communication or coordination on what has been or what needs to be translated. To date, there is no readily available data on existing translated materials to make accurate assessments of their demand and supply, version updates, quality, and accessibility. Absent the mechanisms or processes to share, track, and monitor the quality of translated materials, duplication and inconsistency (including brand) will persist throughout the organization often creating poor quality in-language materials (Table 2).

Addressing Some of the Challenges with Translations through Key NLCP Initiatives

National Coalition for Quality Translation in Health Care
Since there are no nationwide benchmarks nor agreement on how to ensure quality health care translation, NLCP led the development of and convened the National Coalition for Quality Translation in Health Care (NCQTH or Coalition) in 2004, with funding support from The California Endowment.^d The formation of this Coalition represented a groundbreaking effort to bring together diverse key stakeholders and content experts (Figure 1). By leading the efforts of this Coalition, KP hopes to inform and influence industry policy and practice.

Some of NLCP's major accomplishments to date include establishing a quality process for health care translation and working towards standardizing health care terminology in languages other than English. With the help of the Coalition, a standardized Spanish Health Care Glossary was completed and field-testing is in progress. The next phases of the Coalition's work include standardizing KP's glossaries in Chinese, Vietnamese, Korean, Russian, and Armenian. By providing tools and expertise, the Coalition serves as a valuable resource to help health care and language professionals adopt guidelines and standards for translation. Thus, the Coalition's work impacts both KP and the community at-large by improving comprehension and consistency of in-language materials.

Figure 1. National Coalition for Quality Translation
in Health Care organizational structure.

Research Agenda: Quality and Cost Study

With a grant from The California Endowment,^d NLCP examined whether instituting a quality assurance process yielded higher quality, saved turnaround time, and decreased costs for translating written materials. The process compared the error rates of four well-known independent vendors with a model developed by the San Francisco Center of Excellence for Linguistic and Cultural Services (SF COE). This study found that KP's model for assuring quality translation yielded the lowest average error rates compared with the other vendors, 38% cost savings and an average time saved of 51%.^e Interestingly, highest quality does not correlate with highest cost, however, the least costly vendor produced the lowest quality translations.

Strategic Directions

On the basis of clinical, operational, and field experiences, along with validation from our translation survey and research, the necessity of a translation infrastructure has become an organizational imperative. As an integrated delivery system, KP is well positioned to leverage cutting-edge technology, operational expertise, and a proven quality translation model. Instead of functioning in silos, medical facilities and departments Programwide can benefit from utilizing a centralized translation infrastructure and a standardized quality translation process.

NLCP has created an enterprisewide infrastructure model, and leads the strategic collaboration, partnership, and contribution of all regions. As such, our organization will be able to ensure quality review, eliminate redundancy, contain costs, and share resources across the Program. More importantly, our diverse membership will benefit from accurate, consistent, and culturally and linguistically appropriate written materials throughout the Program. Thus, the enterprise approach can positively impact and improve service quality, and address health and health care inequities related to language barriers.

What Providers and Staff Can Do Now

As NLCP continues to advance the development and implementation of the centralized translation infrastructure, providers and staff can take some immediate action steps. (See Sidebar: Action Steps.) v

Acknowledgment to our reviewers: Ronald Knox, VP and Chief Diversity Officer; Dennis Lum, VP of Channel Strategy and Systems; Merri E Keeton, National Linguistic and Cultural Programs; Deborah Gould, MD, Pediatrics; Glenda Carroll, Patient Safety; Rakesh Shah, National Compliance; and Yanping Dong, Emerging Markets.

^a For more information, please visit the Department of Justice Web site at: www.usdoj.gov/crt/cor/coord/titlevi.htm.

^b For more information, please visit the Office of Minority Health Web site at: www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15.

^c The majority of responses were from Northern and Southern California.

^d The California Endowment Grant Number 20012268

^e This study tested a sample set of documents in Spanish representing topics in health education and member marketing.

References

1. Perera, A. Pharmacies try to bridge labels' language barrier. Orlando Sentinel. Orlando, FL. 2006Oct 6. Section A. Available at: www.orlandosentinel.com/news/local/orange/orl-asecprescriptions 06100603oct06,0,6321533.story?coll =orl-home-headlines.
2. Calderon JL, Beltran RA. Pitfalls in health communication: healthcare policy, institution, structure, and process. Med Gen Med 2004 Jan 7;6(1):9.
3. Freilich A, Ku L. The Urban Institute. Caring for immigrants: health care safety nets in Los Angeles, New York, Miami, and Houston. Kaiser Commission on Medicaid and the uninsured. Washington DC: The Henry J Kaiser Family Foundation; 2001 Feb. Available at: http://aspe.hhs.gov/hsp/immigration/caring01/index.htm.
   

Action Steps

Before using translated materials:

1. Make sure that an English source document is available for your review.

2. Verify that there is a match between the English version and the translated version (ie, an English version of a genetics questionnaire was updated, however, the translated version still exists in the older version).

In the absence of these two criteria, the quality of the translated documents is highly questionable. Please alert your facility/department designee responsible for translations.

Be a change agent and get involved in improving patient-centered communication:

­ Participate in the National Coalition for Quality Health Care Translations and other NLCP initiatives.

­ Seek opportunities to increase your cultural and linguistic skills to create a sense of welcome and trust with your LEP/NEP patients.

For more information on the progress of the Enterprise-wide Translation Infrastructure, the Coalition, and consultation, contact National Linguistic and Cultural Programs, National Diversity at 510-271-6386.