When 18-year-old Willie Ramirez was rushed to a Florida hospital on January 22, 1980, his family had no idea that linguistic and cultural barriers would lead to a devastating misdiagnosis.1 Willie arrived at the hospital comatose, and his Spanish-speaking Cuban family told doctors he was “intoxicado,” a word that is used when a person feels ill after eating or drinking. But the doctors did not understand the word “intoxicado,” erroneously thinking that Willie was “intoxicated,” or overdosing on drugs. Doctors ordered toxicology tests. The family insisted that drugs were not involved, but did not push the doctors out of respect for authority figures. It took doctors two days to discover his true diagnosis, an intracerebellar hematoma. By then, damage to Willie’s brain was so severe that he was left quadriplegic.
Willie Ramirez’ story was widely-reported, and brought attention to the medical tragedies that can occur because of linguistic and cultural barriers between providers, patients, and their loved ones. In light of these stories, health care systems are coming to understand the importance of using qualified interpreters to ensure the safety, equity, and quality of health care.
The United States health care system is adapting to better serve an increasingly diverse patient population. In particular, health care organizations are designing care that meets the needs of patients who have limited English proficiency. Two major federal initiatives have been enacted to ensure that patients with limited English proficiency receive high quality care: Title VI of the Civil Rights Act of 1964, which requires recipients of federal funding to provide language assistance services; and the Culturally and Linguistically Appropriate Services (CLAS) standards, developed by the Office of Minority Health in 2000. CLAS requires health systems to provide language assistance and materials translated in patients’ preferred languages, among other standards for delivering culturally and linguistically appropriate care.
Willie Ramirez’ story shines light on the serious consequences that arise when patients, and their family members and friends, do not have access to providers who understand their language and culture. For example, patients with limited English proficiency tend to have longer hospital stays and are at greater risk of infections, falls and pressure ulcers due to these long stays.2 Providing bilingual interpreters is one way to ensure quality care for patients with limited English proficiency, but not every patient has access to interpreters. In some cases, not enough interpreters are available due to supply or affordability. Other times, systems rely on untrained bilingual staff or patients’ family members and friends to act as interpreters. Systems need to think creatively to increase patients’ access to well-trained, high quality interpreters.
Kaiser Permanente Solution
Patients with limited English proficiency need linguistic services at each point of contact in our system, including call centers, hospitals, pharmacies and medical offices. Through the Qualified Bilingual Staff Model, Kaiser Permanente identifies bilingual staff members of all types—such as doctors, nurses, medical assistants, and receptionists—assess their language skills, and provides them with comprehensive training based on their level of linguistic competency. Staff members can attain three levels of QBS training:3
- Level 1, language liaison. Staff converse in English and the patient’s preferred language, and provide directions, simple instructions, and interpretation that does not require medical terminology.
- Level 2, language facilitator. Staff are able to give simple medically and/or non-medically related instructions within their scope of practice, conduct simple translations, and provide interpretation in simple clinical encounters.
- Level 3, designated interpreter. Staff can conduct more complicated translations, provide interpretation in simple- to moderately-complex clinical encounters, and can act as interpreters in a group, class or conference setting.
A defining characteristic of the Qualified Bilingual Staff Model is its focus on developing both linguistic and cultural competency. Interpreters must be proficient in both English and another language, and they must also understand the cultural context of the languages and the health beliefs and values of the patients they serve.
As of 2013, over 11,000 staff members in all seven of our regions have trained in the program. The Qualified Bilingual Staff program has positively impacted workplace culture because it emphasizes the importance of each staff member playing a role in delivering linguistically and culturally appropriate care. “We are seeing enhanced morale and a greater sense of responsibility among our staff,” says Gayle Tang, senior director of National Diversity and Inclusion. “Staff members really feel like they are serving as part of a team, and that they are accountable to one another in providing quality care and services.” In 2006, the program won the National Committee for Quality Assurance’s Recognizing Innovation in Multicultural Health Care Award. In 2013, Kaiser Permanente received the National Corporate Leadership Award from the Migration Policy Institute, recognizing our leadership in providing culturally and linguistically appropriate health care and services.
Practical Implications and Transferability
The Qualified Bilingual Staff model can help health systems deliver high quality interpretation services in a cost-effective manner by making use of staff already on hand. Key enablers of the program include: obtaining leadership buy-in, having program administrators on-site, forging partnerships with labor, management and clinicians, and fostering organizational commitment to education, training, assessment, and program monitoring.
Kaiser Permanente is sharing the Qualified Bilingual Staff Model with our community partners across the nation by offering consultation, training, and technical assistance to organizations who want to adopt it.
For more information, please visit:
Kaiser Permanente Institute for Health Policy at http://www.kp.org/ihp
1 Price-Wise, G. (2008, November 19). Health Affairs Blog. Language, Culture, And Medical Tragedy: The Case of Willie Ramirez. http://healthaffairs.org/blog/2008/11/19/language-culture-and-medical-tragedy-the-case-of-willie-ramirez/
2 Agency for Healthcare Research and Quality. “Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals: What We Know About Safety and Limited English Proficiency.” http://www.ahrq.gov/professionals/systems/hospital/lepguide/lepguidesumm.html#what