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HAAB Backup 04/11/1996 Backup Hispanic Affairs Advisory Board Meeting April 11, 1996 BOARD OF COUNTY COMMISSIONERS HISPANIC AFFAIRS ADVISORY BOARD SPECIAL MEETING AGENDA THURSDAY, APRIL 11, 19966:00 PM NAPLES COMMUNITY HOSPITAL TELFORD CENTER SUBJECT: NCH POLICY RESTRICTING EMPLOYEE USE OF NATIVE LANGUAGES 1) Determination of quorum. 2) Meeting called to order. . Frank Rodriguez, Chainnan:-minutes oflast meeting moved to next meeting for approval and order of business. 3) Frank Rodriguez:- Introduction of Board members. 4) Introduction of Mr. William G. Crone, President, and other representatives of Naples Community Hospital. 5) Frank Rodriguez, Chainnan:- Opening statement and subject of this meeting. 6) Individual statements by HAAB Board members. 7) Statements by Mr. William G. Crone, President, Naples Community Hospital, executives and representatives from Naples Community Hospital. 8) Panel discussion. 9) Comments/questions from members of the public. 10) Frank Rodriguez, Chainnan:- Closing statements and request for resolution. 11) Mr. William G. Crone, President, Naples Community Hospital, closing statements. 12) Meeting adjourned. * * * * * * * * * * * * 1) 2) 3) 4) 5) NOTICE OF MEETING HISPANIC AFFAIRS ADVISORY BOARD THURSDAY, MARCH 28, 1996 . 0 P.M. ITY PARK HIRST STREET LEE, FLORIDA * * * * * * * * * * AGENDA ief remarks to the der of business ist t County Attorney Advisory Board Old Business - 5A) Subcom ittee suppor 5B) Meeting Communi Policy repo: Q re letterhead and clerical eduled between HAAB and Naples re NCH Language Restriction '. 5C) Speaker frollt Sheriff's Office reporting Hispanic youth relations 6) New Business 7) Open session for pUblic comments 8) Meeting adjourn March 13, 1996 Naples community Hospital P. O. Box 413029 Naples, Florida 33941 Attention: Dolph W. vonArx, Chairman of the Board William G. Crone, President/CEO Frances D. Green, Senior vice President, Patient services Re: Collier County Hispanic Affairs Advisory Board/Naples Community Hospital Language Restriction Policy Dear Ladies and Gentlemen: The Hispanic Affairs Advisory Board of Collier County was appointed in 1991 by the County commission to identify areas of concern unique to the Hispanic Community of Collier County and to make recommendations to the commission to properly address such concerns. In compliance with this mission this Board holds monthly public meetings allowing members of the Community to voice their concerns, problems and needs. As a result, the Board initiates a process of fact finding and investigation in the area of concern with parties believed to be part of the subject issues. During our last meeting on February 29, 1996, members of the public brought to our attention a certain unwritten policy, that Naples Community Hospital recently made public in the local newspaper, under which you prohibit your employees from speaking languages other than English. Given the fact that in certain circumstances, a significant number of Hispanics are employed by Naples Community Hospital at different levels and that Naples Community Hospital provides medical services to people of diverse nationalities and cultures, we perceive such a restrictive policy to be a threat to the best interest of our local economy, culture and use of our autochthonous language. It is the purpose of this letter to request that a meeting be scheduled within the next ten days, at a mutually convenient time, with representatives of Naples Community Hospital's March 13, 1996 Page 2 directors, executive management and this Board to openly and fully discuss this unwritten policy and related concerns. Chief Assistant County Attorney Ramiro Mafialich is the County staff liaison to the Hispanic Affairs Advisory Board. Please respond to this request by calling HAAB Chairman, Frank Rodriguez at 435-7635 during regular office hours and/or providing a written confirmation for the meeting through the Office of the County Attorney at 3301 East Tamiami Trail, Naples, Florida 33962. Your prompt response to this request will be greatly appreciated. Sincerely, ~, Frank Ro Hispanic Board 110075 cc: Latin American Business and Professional Association HAAB Members Board of County Commissioners Ramiro Mafialich, Chief Assistant County Attorney John N. Briggs, M.D., Immed. Past Chairman Richard W. Moultan, First Vice Chairman Hubert E. Howard, Second Vice Chairman Paul L. Hertenstein, Treasurer Edward A. Morton, Assistant Treasurer Helen E. S. Shick, Secretary Richard C. Bradley, Trustee Joe B Cox, Trustee Norman A. Herren, Trustee Robert L. Kampfer, D.D.S., Trustee Daniel C. O'Neil, Trustee Charles J. Sanders, Jr., Trustee Miles B. Scofield, Trustee William Sinclair, Trustee MEMORANDUM TO: Mr. Ramiro Manalich FM: Mr. Neil Morales DT: March 10, 1996 RE: Revision Of January 3 I, 1996 Minutes As pursuant to our last Hispanic Affairs Advisory Board meeting on February 29, 1996, I have revised the Minutes for the January 3 I, ] 996 meeting as the board has asked. Unfortunately, I have received no word from Mr. Victor Valdez on his corrections for these Minutes. If you have any questions, please call me: 774-4985. ,) 'r'; "',1 ,"j'1 , 03/29/96 17: 32 ~1 813 262 6267 F N B OF NAPLES 141 001/005 FRANK RODRIGUEZ FAX TRANSMITTAL TO: RAMIRO MANALICH DATE: 03/29/96 RE: NON ARTICLES ON NCH LANGUAGE POLICY PAGES: TOTAL 5 INCLUDING THIS ONE. COMMENTS: FOR YOUR INFORMATION AND DISTRIBUTION.. 03/29/96 17:32 ~1 813 262 6267 03/28/96 16:04 ~B1326J4B16 F N B OF NAPLES ~ 0021005 NAPLES DAILYNEWS ...... F N B OF NAPLES IaJ 003/004 NCH lMPLE S LANGU Naples Daily News Section: Ambience Edition: FINAL Published: 02117/96 Page: A01 NCH implements new language policy: The hmpital says patients and visitors were made uncomfortable by employees speaking foreign languages. By LIZ FREEMAN Staff Writer Employees of Naples Community Hospital have been directed to not s:Jeak their native language in front of patients and visitors who cannot understand them, r.. CH officials say. The unwritten policy, which carries with it no written penalty for violilting it, stems from a handful of complaints received in recent weeks that some employees WC:'C making patients and visitors uneasy by speaking foreign languages in patient rooms and in IuJ Ilways, said Fran Green, senior vice president of patient care services at NCH. Green met with do;, )artment directors so they could inform their employees to refrain from doing so, she said. The directive is not aimed to promote an English-only institution; emp .oyees can speak their native language on breaks, in the cafeteria or quietly among themselves, she said. It applies to all 2,000 employees of the NCH health-care system.. Because physicians an: not drawing salaries from NCH they cannot be told to abide by it.. she said. This isn't the first time that NCH has received such co:nplaints but it i:, prompting the hospital to eliminate its practice of having bilingual employees serve as interpret'; IS for patients and physicians, she said. That spells an end to the small compensation that tl: :se employees were receiving for their interpretive services. Green could no; say how many" nplo: 'ees it affects or how much additional compensation they were receiving. To replace that program she plans to contract ",ith a:; i,:lIerpretive serv: :e, sk said Hospital employees and volunteers discussed the new policy in a haIl Ii = th,~ housekeeping department Friday afternoon. They were speaking Spanish, but spoke in : ow tones. There were no patients in sight. "This is the stupidest rule I ever heard of," said one voluuteer. who did: l't wam his name published. He said he did not fear retaliation by the hospital but felt uuceJ moruble criticizing the hospital in a newspaper article. Hospital employees clso ~efused to speak for publication. The volunteer spoke Spanish although he is not an Hispanic. He said hi 'leamed Spanish in a South American county, where he lived for 10 years. "People think we are talking about them when we speak Spanish; we're not. We're talking about things that interest us and don't concern them." be said. Lee Memorial Hospital in Lee County has no v,1ir"'il pc.iic" regarding.. ;hat l:mguage employees can speak in front of patients but similar:o wh2.; ~CH is dom ~, employees are tOld to be courteous, said spokeswoman Karen Krieger. Tha includes not makin. patients feel uncomfortable by speaking a language they can't unde=d. she said. ColumbialHCA Healthcare Corp., which owns three hospitals in Lee C mnty. likewise advises employees of the same, said spokesman Randy Smic::. Green said the intent is to rn2ke patients and visitc:5 ftc' as cornforublJ as possible in an 03/28/96 16:0S ~8132634816 NAPLES DAILYNEWS ....~. F N B OF NAPLES tal 0041004 enviromncnt that's inherently stressful_ "(When) someone comes in a room and speaks a language they (patieJ:lts) don't understand, people get amid," she said.. .So I challenge everyone to assist us, treat tllem like anyone: in your own home. "We're not denying anyone the opportunity to speak a language that tlJ.,:y want on lunch break or even quietly among themselves," she said, addingtbat classes are offo:'red through the hospital for employees to learn another language orto improve their English. Having employees serve as inte:tpretcIs wasn't working because it often meant calling them away from their jobs, which could have a detrimental effect on the hospital's operatiOll, she said. Besides that, when an interpreter-wasn't available somebody else woul,! pinch hit and the inteIpretation of what the patient or physician was saying might not be z.,; accurate, she said. Any change in m(,~";T1g could have a serious consequence on a patient's care. "So, we're trying to back off from that,. sbe said.. .We're looking for 31ew way to assist physicians. We're looking at hiring our own interpretive service and put ;t out to bid.. It's probably the easiest way to go_" For about 15 years Lee Memorial has had employees serve as interpretms and it works well, Krieger said. They have a list of 153 employees from the 3,700 employell systemwide, representing 28 languages. "It is voluntMy and once a year we recognize them." sbe said.. "They de a nice job." Stale law under a patient bill of rights requires that a hospital make ev,:ry effort to provide an interpreter when needed and so Columbia has a full-time Spanish interpr :ter and contracts with others, Smith said. Sometimes employees are used for translation but the: first choice is to use professional services, he said_ 03/28/96 16:04 ~81J2634816 NAPLES DAILYNEIVS ...... F N B OF NAPLES ~ 002/004. NAPL Na les Dail Section: Editorials Eon: Published: 02l231S6 Page:D04 Naples Community Hospital LaD.eouage rule awkward, no matter how you say it Unwritten rules often spring from fear and mistrust, and make matters \','OlSe. The new language policy at Naples Community Hospital has its roots in a lack of tmdCIStal.ding and the failure to look for an mswer from those closest to the question. The policy directs employees to refrain from speaking foreign languages in patient rooms and hallways, in from ofEoglish-spcaking patients. Employees may spea..\ in a foreign language quietly among theJ:nselves.That assumes English is the first language of all patients. "What will the hospital do fOl patients from Germany or Frnnce?The motive may be humanitarian - ttying to bend over back", lrd to avoid upsetting patients who arc already distracted by their health - but the policy sends the wrong signal to hospital employees, patients and families. To be sure, the comfon of pati ents IDUst be foremost in the minds of hospital administrators. Surely, that comfort level is uppernost ill the minds of hospital staffers as welL Yet this policy tells those workers they are !iifii rent, they are resented and distrusted by those they serve, and they should keep quiet. This appf: lIS to have the potential to undermine the quality of care at an institution whose stock in trade is Its ability to serve, Did it really take a directive from on high,to achieve those results?A COmmittf:~ of staffers, sensitive to patient concerns, would likely have reco=ended the same course, but. ..ith far more finesse.In issuing its new language polic the hos ital administration used a chain ;aw when a scalpel would have done the . ob. 1edhd30Science cp26Something new unde> the sUn cpl O.5c1IIFifty years ago, th e were ody 96 elements on periodic ttble - hydrogen. helium, silver, sulfur, etc. - and as reee as 1990 ody I03.Scientists' Europ, have just discovered No. 12;'no name yet for the new em, which is a dis"tant .elan of ~nc aod h~ so far existe riefly only as a single atom. en that took se\'e:al weeks of ,nbarcing a lead r.arget with billi of zinc atoms, The chief disc erer, German physicist PeK' bruster, says the end may be ear: There won't be an element 0 and there probably WOl' 't ev ,. be an element l30.So cheer . chemistry and physics majors. ere are still some elenents ou there waiting to be discovered an one of them may have your name n iL /edhd24Gt est editoD The presidential price c ck cp 1 0.5c111 One would think Gap candidat<,; for preside . are running for the job of ading up a supermarket chain. Ho else can Oill e;,:plam the fl over whether Lamar Alexande . knows the price of a gallon of . or a do; en eggs?T 0 put . s little bit of political farce int onte>.."!, it must be remembered t four~. = ago President ush was ridiculed when it appeared Ii d no idea of the mechanics 0 per narke, checkout counters ... . He was thought to lack common touch - which shaul . !Ve been fai:ly obvious, :myway.It might saVe time To stipulate m presidential candidates are ,: ~ti::r" enQl'gh no to avoid having to do the family grocery shopp ... . When's the last time {o~,W Pat or Bob or Steve or Lamar or Bill in the family supermarke ess tiley happened t< be tb~ to shake hmods with voters ... or check on the price of milk? - The Toledo Blade HOSPITA News ~. St~iiiftt1i7 ~11.Y;/9b ) ---. Editor, Naples Daily News: .In response to your editorial of r"eb. 23, we would like to clarifY our PoSilion on language usage here at NCH (Na): les Community Hospital). Our mission is to care for pen,ms who are ill - folks who are in the ho;;pi- tal are under stress and in many ca ses are frightened. Our aim is to make th'~se people as comfortable and as secun~ as Possible. Part of this process is to ask our staff and employees to be awarl' of the patients' and families' needs in m, ny areas, including language. We have asked our staff to try and re- Spond to those needs by speaking in I he language of the patient and their falni- lies if they have the ability. We ree'lg- nize that English is not the first langu?ge of all patients or staff members. In lil:ht of this we have an interpretive serv: ce available to assist in 95 different Ii n- guages since clear communication is 's- sential in a medica! ,etting. We ;re trying to remain focused on our patie ltS and their needs while they need to be with us. We havc classcs in bUlh Spanish ,Iod English language instruction .offered at the hospital so that all staff can commu- nicate more clearly with each othcr "od with our patients. In addition we n lW have a German translator available in response to the growing number of G '1'- man residents and tourists in Coll er County We hope that everyone understar ds that our program is a response to I'd- tlents' needs James G. Bingham/Nar c,s SpeCial r'\SSlstan: LC the Preside!' [, The NCH Hecc'tllcare Syslc C]l 04dJI,9fj L6:2fi .".-.. ~, k L:I 2H2 fj2H7 F N )j UF NAPI.ES '-'-~-""~'-""- IdJOOIIOOl 1J;'L f#fS' 'M/JlC ~'/l.f ~n..sP~r DMd.o j/).i:'e."Tt;~ ~, IHN{))::c./ee ~M~VI7IIl f)Aol2,..'~ ~rb--grfl.4/IAl5. ____ ____ . ~-.r. ~. AJIJ,__ 't'~4z9Js..~ft~~~------- _____~s__~ - ClZ5-_____ ~ 1/. (, v.s:f.!ll__dt'.(] "'~:!-:.'--n_..______ ? '?] -j ~_E ;'_________ ~~- ]5Y(l1a\){\!L_JIt] g~ ._ __ _ ~1=--l3.1 Zd-:___ t>:.:.___ Ll0.-m.~-1l1klL.. _.n___ _ ,U_ __ ~1_~]J 7~____.___ _' - !..vIc:.tOfi.j\._~ t;;'s -(JoIl4~A-l,J) 7'i3_-=]~:-':L~ ___ ______ -. t'e"Lpe..Gt..fU\___ . .. n_.___(Pe.l_:7..~;'i'i__________________m___ -- ___VU-en h: --lLeU4 -__.______lo;, Z=k.':i 'l~_____ n____ _.~\~ye\__-A:_'N..Q.,,)~_~L_ ..___ ______._6?52-Z9._~L: ___ .__n._________ ~. NOCGL_ _CZOr.n.e:L___m___~S7_--~.i~~_~ .________u _1\\~.cH,d12~___.__rJ1ffiL. ______ __ ________ 2)e,:55/c::..._ frQ"V'1\~--:Z__ f..;, 5"/ -::~:12:'>:5_________ Ett::J; u_= ~i-f~'!~;i ~_~__H~~__ 'n 7>1 J.c, . &W/~__n._ _____ ._.. 0S:-~- .~_~Le_c. ._ .____________.__ _.L~OL9.-~e.:zA--_-- . _________~_S7 -,~_'Ij'~ . -:luff'! tf~d<<~&!:.. __un __mQ~2=_gth:~?.._..___________.. __.C;J;; ~ t/}t2/iIA,Itf,€ 1'_ __... _ m _ _ 05-'7 ' _'-I C. ~?-\ __m________ /~~;;./-~:0t:2/f? ;( / - .~-Pdyz---[ ?nQ ~ ~_ -=6.CZ _13("__ _._____ . -__~-S~~---.. - ..-.----...-3s~=__Q([]I)__ ____._______.____.__ _. _._~rna.s-a..-----t?'dU:c..S;y ...____ ___lU::::_Q .;I. G3 ___________________ --Gt f.~~tc! _B_.._~AoY'____u___6>If:'_-55-tjL . _____ ________ ..... i;:;n{W- tfi~Yi,~---- ;'-"~ 012..cLr N.t\ 657 - -UC{, 0 ~M)t16 03/29/96 17:32 ~1 813 262 6267 F N B OF NAPLES I4J 001/005 FRANK RODRIGUEZ FAX TRANSMITTAL TO: RAMIRO MANALICH DATE: 03/29/96 RE: NON ARTICLES ON NCH LANGUAGE POLICY PAGES: TOTAL 5 INCLUDING THIS ONE. COMMENTS: FOR YOUR INFORMATION AND DISTRIBUTION. 03/29/96 17:32 ~1 813 262 6267 03/28/96 16:04 ~8132634816 I' N B OF NAPLES Ij!J 0021005 NAPLES DAILYNEWS +H F N B OF NAPLES 1aJ003/004 NCH IMPLEMENTS LANGU Naples Dally News Sect/on: Ambience Edition: FINAL Published: 02/17/96 Page:A01 NCH implements new language policy: The ho~;pital says patients and visitors were made uncomfortable by employees speaking foreign languages. By LlZ FREEMAN Staff Writer Employees of Naples Community Hospital have been directed to not s:>eak their native language in front of patients and visitors who cannot undasrand them, r- 'CH officials say. The unwritten policy, which carries with it no written penalty for violClting it, stems from a handful of complaints received in recent weeks tha1: some employees W(:'C making patients and visitors uneasy by speaking foreign languages in patient rooms and in m, Uways, said Fran Green, senior vice president of patient care services at NCH. Green met with de)arlment directors so they could inform their employees to refrain from doing so, she said. The directive is not aimed to promote an English-only institution; emp .oyees can speak their native language on breaks, in the cafeteria or quietly among themselves, ihe said.. It applies ro all 2,000 employees of the NCH health-care system. Because physicians an: not drawing salaries from NCH they cannot be told to abide by it, she said.. This isn't the first time that NCH has received such complaints but it i:; prompting the hospital to eliminate its practice of having bilingual employees serve as interpret':rs for patients and physicians, she said. That spells an end to the small compensation that tl: ~se employees were receiving for their interpretive services. GTeen could nm say how many (, cnployees it affects or how much additional compensation they were receiving. To replace that program she plans to contract ",ith an interprctive serv:. :e, sh,: said. Hospital employees and volunteers discussed the ne\v policy in a hall II = the housekeeping department Friday afternoon. They were speaking Spanish, but spoke in :'ow tones. There were no patients in sight. "This is the stupidest rule I ever heard of," said one volunteer, who did: l't wa1Jt his name published. He said he did nor fear retcliation by the hospital but felt unC(J :nfort:3.ble criticizing the hospital in a nev..spaper articlc. Hospital employees also refused to speak for publication. The volunteer spoke Spanish although he is nor an Hispanic. He said hi learred Spanish in a South American county, where he lived for 10 years. "People think we are talking about them when we speak Spanish; we're not. We're talking about things that intcrest us and don't conc= them." he said. Lee Memorial Hospital in Lee County has no wrirtzn poiicy regarding " !hat language employees can speak in front of patienIS but similar to '-'hz.t NCH is dom ~, employees are told to be courteous, said spokeswoman Karen Krieger. Thz.t includes not makin ~ patients feel uncomfortable by speaking a language they can't uncie=d. she said. Columbia/HCA Hea1thcare Corp., which ov,1!S three hospitals in Lee C lunty likewise c.dvises employees of the same, said spokesman R;mdy Smith. Green said the intent is to make patients and visitors feel as comfortabll ' as possible in an ........u "'vl <.I.... 03/28/96 16:05 ~8132634816 NAPLES DAILYNEWS H"' F N B OF NAPLES Ii!JOO4l004 environment that's inherently stressful. "(When) someone comes in a room and speaks a language they (patieJ:'ts) don't unde~d, people get afraid," she said. .So I challen.,<>e everyone to assist US, treat tltem like anyone in your own home. .We're not denying anyone the opportu!lity to speak a language that th.:y want on lunch break or even quietly among fh""'SE'lves," she said, addingtbat classes are off" red through the hospital for employees to leam another language or to improve their English. Having employees serve as i!lteIpreters wasn't walking because it Oftell meant calling them away from their jobs, which could have a detrimental effect on the hospital's operation, she said. Besides that, when an interpreter wasn't available somebody else would pinch hit and the interpretation of what the patient or physician was saying might not be 2.'; accurate, she said. Any change in me"ning could have a serious consequence on a patient's care "So, wc're trying to back off from that, " she said. "We're looking for a .lew way to assist physicians. We're looking at hiring our own interpretive service and put ~ t out to bid. It's probably the easiest way to go." For about 15 years Lee Memorial bas had employees serve as interpretl!{S and it works well, Krieger said. They have a list of 153 employees from the 3,700 employe,l systemwide, representing 28 languages. "It is voluntary and once a year we recognize them." she said. "They de a nice job." Stale law under a patient bill of rights requires that a hospital make ev.: ry effort to provide an interpreter when needed and so Columbia has a full-time Spanish intexpr'~ter and contracts with others, Smith said. Sometimes employees are used for trarlslation but thc: first choice is to use professional services, he said. 03/28/95 15:04 ~8132534815 NAPLES DAILYNEWS ~.H F N B OF NAPLES 141 0021004, NAPL 0 Na les Dail Section: Editorials Eon: Published: 02123/96 Page: 004 Naples Community Hospital Language rule awkward, no matter how you say it Unwritten rules often spring from fear and mistrust, and make matters \', 'orse.The new language policy at Naples Co=unity Hospital has its roots in a Iaclc of understar.ding and the failure to look for an answer from those closest to the question. The policy diIccts employees to refrain from speaking foreign languages in patient rooms and hallways, in fron1 ofEngJish-spe-'lking patients. Employees may speak in a foreign language quietly among themselves.That: assumes English is the first language of all patients. What will the hospital do f01 patients from Germany or France?The motive may be humanitarian - trying to bend over back'-\'lrd to avoid upsetting patients who arc already distracted by their health - but the policy sends the wrong signal to hospital employees, patients and families.T 0 be sure, the comfon of pati ents DlUst be foremost in the minds of hospital administrators. Surely, that comfort level is uppernost ill the minds of hospital staffers as well. Yet this policy tells those workers they are p.iff, rent, they are resented and distrusted by those they serve, and they should keep quiet. This appe: lIS to have the potential to undermine the quality of care at an institution vvhose stock in trade is ,ts abjJjty to serve.Did it really take a directive from on high,to achieve those results?A committe ~ of staffers, sensitive to patient concerns, would likely have reco=ended the same course, but. .ith [.11' more finesse.In issuing its new language polic the hos ital administration used a chain iaw 'when a scalpel would have done the - ob. ledhd30Science cp26Something new unde',. the sUn cpl O.5clllFifty years ago, th e were oPly 96 elements on periodic t lble - hydrogen, helium, silver, sulfur, etc. - and as rece as 1990 only l03.Scientists' Europ' have just discovered No. ]2;- no name yet for the new em, which is a dis"l2Dt relan of ~nc and h<"S so far existe riefly only as a single atom. en that took seve:al weeks of . nbarcing a lead larget "With billi of zinc atoms. The chief disc erer, German physicist Pete' bruster, says the end may be ear: There won't be an element and there probably wor't ev ~. be an element 130.So cheer . chemistry and physics majors. ere are still some ele] lents 0 there waiting to be discovered an one of them may have your name niL ledhd24G!: ~st editoD The presidential price c ck cp 1 O.5elll One would think: Gap candidate,; for preside . are running for the job of ading up a supermarket chain. Ho else can OIll eXlllain the fl over whether Lamar Alexande . knows the price of a gallon of . or a do, en eggs?T 0 put . s little bit of political farce int onte},:t, it must be remembered t four:. = ag.o President ush was ridiculed when it appeared Ii d DO idea of the mechanics 0 per narket checkout COlmters .n . He was thought to lack common touch - which shoul . lve been fairly obvious, 2!lyway.It might save time to stipulate ill presidential candidates are ,: ~thy enough ... to avoid having to do the family grocery shopp ... . When's the last time {O~,w Pat or Bob or Steve or Lamar or Bill in the family supermarke nless they happened t.; be tb~ IO shake hands with voters ... or check on the price of milk? - The Toledo Blade HOSPITA News ~, St~ig.<<ta1i7 '!l.Y;/9 b ) -----. Editor, Naples Daily News: In response to your editorial of Feb. 23, we would like to claritY our position on language usage here at NCH (Naj: les Community Hospital). Our mission is to care for per~;'ms who are ill - folks who are in the ho::pi- tal are under stress and in many C~I ses are frightened. Our aim is to make th'~se peopl.e as comfortable and as secun~ as possible. Part of this process is to ;lsk our staff and employees to be awarE' of the patients' and families' needs in miny areas, including language. We have asked our staff to try and re- spond to those needs by speaking in I he language of the patient and their falni. lies if they have the ability. We ree'}g- nize that English is not the first languDge of all patients or staff members. In lil:ht of this we have an interpretive serv; ce available to assist in 95 different I:!l- guages since clear communication is ~s- sential in a medical setting. We ; re trying to remain focused on our patie Its and their needs while they need to be with us. We have classes In both Spanish ,I nd English language instruction .offered at the hospital so that all staff can comniU- nicate more clearly with each other ilnd with our patients. In addition' we n)w have a German translator available in response to the growing number of G 'r- man residents and tourists in CoIl er County. We hope that everyone understal ds that our program is a response to I >a- t'ents' needs. James G. Bingham/"2[ cs SpeCla! ASSistant tc: the Preside) [, The NCH Healthcare SyslE 11 OFFICE OF THE COUNTY ATTORNEY Memo From: Sue Filson, AUV~ ~sistant, Board of County Commissioners Ramiro Mafialich, Chief Assistant County Attorney To: Date: October 4, 1996 Re: Hispanic Affairs Advisory Board Minutes Attached please find the approved minutes for the April II, 1996 special meeting with Naples Community Hospital and the April 25, 1996 regular HAAB meeting, both of which were approved at the October 2, 1996 Hispanic Affairs Advisory Board meeting. With regard to minutes from prior HAAB meetings, please be advised as follows: at the March 28 meeting held in Irnmokalee, there was no quorum and thus no official meeting or formal minutes. However, due to the community turnout, we went ahead with an informal discussion and I have written notes on same. The May 1996 meeting was canceled by Frank Rodriguez due to the Memorial Day holiday and a short agenda. There was no quorum at the June 20 and the July 25 meetings and thus no official meeting or formal minutes. It was decided by Chairman Frank Rodriguez that due to the "quorum problem" and my busy schedule at that time that no meetings should be scheduled until September when all the members would be back from their summer vacations. However, the September 26 meeting was postponed until October 2, pushing the October meeting into November - November 7th to be exact. These minutes are provided for your information and records. Please contact me if you have any questions or comments. RM:gb Attachments cc: David C. Weigel, County Attorney '. ""'T1AP-29-'96 16: 10 ID:DHHS-I') FT;-:3:30-3386 TEL fll]: 4047'"'0%93 1:1097 P02 , ., .-.. ....,~ .' {t.. . , "',t.... DI'ARTMENT Of HIlALTH .. HUMAN SERVICI!S . o lac. lor cr~q AIghll "(II IMTV ~TTfY:~'r:.'I'" ~ . l\F:f. A~lon IV 10 t "''''.U. Tower Allan.. 01. 30323 . , f;~.~ Ie . NOTICE TO COMPLAINANTS ABOuT INVF~~IGATORY USE..'i .' QF PERSONAL INFORMATJC . . AJ a complainant, you Jhould be aware of tJle clrcumstancCJ under which the Office for Civil Rights (OCR) releases Information from a complalnt file. , , AS A POLICY. TIlE OFFJCE FOR CIVIL RIGnT~ docJ not reveal the' ~al1le or other Identifying information about an Individual unleu It Is neceuary for the completion of an investigation or {or enforcement activities agalnst an institution tliat violates. 'civil rlghLt laws, , " or unless required 10 do so under the Freedom of Information Act (FOIA). In general, OCR docs not reveal 10 an Institution under investigation the identity of the person who filed the complaint, unless the person first gives OCR wriHen consent to do so. However, If a complaint is f1Ied against a HJJI.Burton facility. OCR Is require..! 10 send a copy of the complaint to that hutitution. . nlere are two Federal uws governing personal Informallon submitted to all Federal agencies Including the Offico for CIvil RIihts (OCR): TIle Privacy Act Of 1914, (5 U.S.C. 522a) and the Freedom oOnformation Act, (S U.S.C. 522). Thls brief dC3Crlption wUl acquaint you with these , laws. I" FTS 8813 8b .TEl II'.': 4"'473139693 -., ~IRR-29-'96 16:113 ID:DHHS- v ,- -33. _ _ 1:1397 P133 ~. OEPARTMENT OF HEALTH lll. HUMAN SERVICES OHlce lor Civil R10h18 !'legion IV , 0 1 Marlella Tower Allanle I3A 30323 DISCRIMINATION COMPLAINT FORM '; 1. . Complainant: ~""15S /-/ /-<,'-'(,. / ~EV<:~/ (InjlJ.nd parry(lt!.r) roO. l-:So,. 97".0- (Sttwn or R..F.D.) /U<>f;:;/" 5 jC:;t.. 3:19'1/ , ~ (Ciry, Stall! and Zip Code) I~TE~uI/"u;"7~XS . Address: Telephone: { 7'7'/) 0'". 37:>0 (Home) _( 9'// 1 ~-(". J7:ld (Business) 2. Complaint FUed By: I1S 14.-:.70 v;: (S~1f or Repru~nrali",,) Address: (Strut or R.F.D.) (Ciry, Stau and Zip Cod~) Telephone: ( { ) ) (Home) (Business) 3. If you have a representative, would you like to send copies of all future correspondence to that person'] 1 00 YES LJNO 4. Person or Entity who has discriminated against the complainant: Name: ;VC/-I /:fERfLT II CrlA'/'~ <5 Y 57/'=/<-1 Aaency/Facillty: f.e> 1':]0)< '7'/JO:1-'} (Srr~n or R.F.D,) /UAj7I..L:'S, 'pL. '3:3"9 '7// (City, Start and Zip Code) Address: Telephone: ( 7'// 1 -41J~ - 5-<1do Page Two DISCRIMINATION COMPLAINT FORM 5. Complainant was discriminated against because of (check one or more): .x Race or Color Sex I I ] I X Natioua.l Origin Handicap/Dlsabillty Age X LA N(,.!-' PlG-;~: ' When did the alleged discrimination occur? Re1Ieion 6. L..~sr ~ (Date) yE~~.5 7. Has this compiaint been filed with this agency before? U YES (20 NO 8. Has this complaint been filed with any other agency? U YES W NO If yes, please provide Name of Federal agency and/or Court: Name of State agency and/or Court: Name of Local agency: Name of Agency or Court Conlaet Person: Address: (Strut or R.F.D.) (elly, SIal/! and ZIp Catk) Telephone: ( 1 9. If litis complaint has been filed with another Federal or State agency, has the agency . i~ued a ri~ht to sue letter to the complainant? L) YES L-> NO - Page Three DISCRIMINATION COMPLAINT FORM 10. If yes, does the complainant intend to file suit? L..J YES L..J NO OR 11. Has the comp1ainant fIled suit? L..J YES 00 NO 12. Does complainant intend to fIle with another agency? (.AJ YES L..J NO Aaency: I-kS. l)/v/510...J C,;: ,PArlulJ Address: MA_ :::r cu" 13 A- v NO (Strut or R.F.D.) Fr. jWy~,e,s. Pi. (City, Stat. and Zip Cotk) ( '7'7'/ 1 93(,- j'u,"? ~ Telephone: 13. Date when the complainant intends to file: {)(')/V,;: 14. Has efforts been made to resolve this complaint through the internal grievance procedure at the institution or agency? L..J YES (2Q NO 15. If yes, what is the status of the complaint? . .,. . Page Four DISCRIMINA nON COMPLAINT FORM .., 16. Name and Title of the person who is conducting the grievance procedure: tv/A 17. Please desc;ribe the alleged discrimination and how it has affected the complainant: (use additional sheets if necessary) S.c1O JlF1//1ofEo. 18. For what remedies is the complainant asking? .E IV 'po;l!.c;; 1<'7/::"'/ Or "I~ CO"L" 0;:' rr-lOfi~ffL ~i:.C-I..l'-w-T/o,"S 'g't>.g>( ~)( 1'N'9J , C{1/1 L FIN/55 yfcTloA.) CJ I/IL - ;0]<-.. t '- ~.- ~, . p~- . . Page Five DffiCRmfiNAnONCOMPL~FORM 19. Has Ute complainant ftled any oUter complaints wiUt Ute Office for Civil Rights (OCR)? LJYES WNO 20. Whom were Utey f1.Ied against? Name: Agency/Facllity: Address: (Strut or R.F.D.) (City, SltU~ and Zip COtk) Telephone: [ 1 Issue: Date or FlIing: Region 21. If Ute OCR fmds that it does not have jurisdiction over my complaint, I give OCR permission to refer my complaint to the appropriate agency. Additional Comments: Ves / Signature: Date: if/I /7(; . . Pitas/! retum this form to: Regional Manager Office for Civil Rights DRHS, Region IV 101 Marietta Tower, Suite 1502 Atlanta, Georgia 30323 (f UJ:.I"^.K I. MJ:..L",& ur nc.^.....1 n CL nU01^N :)t,I\ V lL.t.,) Region IV 101 Matl.n. Tower AU8I1la GA 30323 CHECKLIST OF INFORMATION REQUIRED [ ] Discrimination Complaint Fonn (Complete with detailed information to describe what agency or facility is involved in your complaint, what happened, when did it happen, did it happen because of race, color, national origin, handicap, age, sex, lack of money, Medicare or Medicaid status?) . [ ] Complainant Consent Form [ ] Complainant Release Form [ J If you (or the alleged injured parties) have a disability or disabilities, please describe the disability or disabilities and send a statement from your/their doctor stating what medical or physical limitations exist because 'of the disability or disabilities. You should also indicate whether the disability or disabilities are permanent. (TItis information is voluntary and confidential, but is nect....ry for this office to determine whether rights have been violated under Section 504 of the Rehabilitation Act of 1973 or the American with Disabilities Act.) [ J If you are alleging a violation of the Hill-Burton Community Service Assurance, please stale whether you (or the alleged injured parties) live or work in the facility's service area, whether you/they are a Medicare or Medicaid client, or whether you/they were denied admission to the facility Of denied treatment in the emergency room of the facility. (J DEPARTMENT OF HEALTlI &.lIUMAN SERVICES Ollie. 10' CIvil RighI> ROO"'" IV 10' 1.4.,1.11. Tow., AIIont. GA 30323 COMPLAINANT RELEASE FORM I hereby authorize lhe United States Department of Heallh and Human Services, Office for Civil Rights, 10 receive material and. Informallon about me pertinent to the investigation of my complaint. TIlls release includes, but is not limited to, personnel records and medical records. I understand lhat lhe material and information wlll be used for aulhorized civil rights compliance and enforgement activities. I further understand that I am not required 10 authorize lhis release, and do SO voluntarily. Signature: Dale: "///?( . , I wish to qu this release in lhe following manner, allhoullh I realize lhb may impede OCR's ability 10 investigate my case. NONE Signature: Date: <r;~/7C I do not w. OCR to reveal my identity to the ins' nder investigation, or to review, receive cOPles of, and discuss material an' rmation about me I"'rtlne~invesLigation of my complaint. I understand lh Ikely to impeje the in If<llloii of my case and may resultln closure of lhe inve on. Signature: Date: Name: PI<<o.., Print ~:. '.lfA.TMINT.. HIALTH . HUMAN 9I.VICE! ,"":$ Ollie_ lor ClyU Rlghll A_glonlV I a 1 M.rl.n. To..", AUent_ GA 30323 .. " NOTICE TO COMPLAINANTS ABOUT INVESTIGATORY USES OF PERSONAL INFORMATION A!J a complainant, you should be aware of tlte clrcumstance!J under which Ihe Office for Civil Righl!J (OCR) relcase!J Information from a complaint file. . , AS A POLICY. TIlE OFFICE FOR CIVIL RIGHTS does not reval tlte' name or otlter identifying lnformal.lon about an Individual unless it b necessary for tlte complel.lon of an investigation or for enforcement activities again!Jt an in!Jtitution Ulat violates. 'civil righu laws, or unle" required to do so under tlte Freedom of Information Act (FOIA). In general, OCR does not reveal 10 an Institution under Investlgation the identity of the pel'3On who filed Ihe complaint, unles!J the person first gives OCR wrillen consent 10 do so. However, If a complalnt is filed agalnst a Hlll.BU!1an facillty, OCR is require.! 10 send a copy of the complalntlo that institution. 111ere are Iwo Federal Laws governing personal Information submitted 10 all Federal agencies ~ Including tlte Office for Civil RIllhts (OCR): 111e Privacy Act Of 1974, (5 U.S.C. 522a) and the Freedom oCInformatlon Act, (5 U.S.C. 522). This brief description will acquaint you wltlt tltese laws. ... . -: .. .. . . ..~... 4 t. ',' .r.')' "1:1, rr ~ . ti~ 'I;~ ;l"~'~ r' .:.. J~; i'l :.. "'/ l"~ .\ f -2-- I. . TIlE PRIVACY ACT protects complalnants from misuse of pcrsonalinfannatlan held by Ulc Pederal Ilovemment. The law applies to records Ulat are kept and can be located by the complalnant's name. social security number, or oUler personal Identificallon system. ., .-;- " Personal lnfonnalion wlll only be used far authorized civil rights compliance and enforcement activllies. Generally, OCR wlll nat release the info.nnation to any oilIer agency or individual uniess the person who supplied the infonnation submits a wriUen consent, or unless release is authorized under the Freedom of Information Act. However, OCR does ~ave th~ authority to refer complalnts to other Federal agencies such as the Department of Justice, the Department of Labor. and the Equal Employment Opportunity Commission ':Yithoutthe complalnant' s pri~r consent. TIlls authority Is provided under the 'routine usc' exception to the Privacy Act. Infannation submilled to OCR may also be given 10 oUler government sllcneles. usually lhe Department of Justice, for enforcement proceedings against an Institution that violates I civll rights laws or regulatlons. OCR may have to reveal pel'3OnallnfamfiUon about a .. I. ' '. complalnant to individuals participating In that phase of the enforcement process. .. ' ., , J J;' . I~ . \ ,~ , .... -t.''''''' - .. '. i . .j.i..... I , , :> ,-" .' " . -]- A complalnant cannot be required to give personal Information to OCR, and no sanctions will be imposed on peuons who deny our request. However, If OCR faIls to obtain information needed 10 11Ivesllgate aHegallons of dlscrimlnatioll, it may have to close the investigation. A complaInant may ask for and review all Ill!: personal malerial in Ius or her Ole kept for Investlllatory uses by OCR (except as necessary to malntain confidentiality of witnesses and other sources). If the person linds any errors In tile Ole, he or she may notify Ihe Office and request corrections. If OCR ~efuses tile request. Ille complainant may appeal OCR's decision to llle Asslslant Secrelary for Management and Budget, Department of Heallh and Human Services. . 2. TIlE FREEDOM OF INFORMATION ACT IFOl.Al gives the public Ule right of access to files and records of Ule Federal government. With some exceptions. tbe Department of HeaJUt and Human Services, must honor FOIA requests, IllOugh our polley Is to do so without releasing a complaInant's name or oilier personal Identification. The Department. Is generally not required to release documents If llle release would Interfere wiUI llle .,..... . . Department's abl/lty to complete Its work; as, for exal'1ple, during an investigation or enforcement proceeding. Aiso' any Federal agency may refuse a request for files or records jf Ute release would be an unwarranted Invasion of an Individual's privacy. ., MEDICAL INTERPRETERS P.o. Box 9745 Naples, Fl., 33941 (941) 566-3720 Mrs. Frances D. Green Senior Vice President Patient Care Services NCH Healthcare System P.O. Box 413029 Naples, Fl., 3394] April 2, 1996 Dear Mrs. Green, I would like to advise you that I have filed a formal complaint with the Department of Health and Human Services, Office for Civil Rights, against NCH Healthcare System. } 7 /? ;:~r I was advised today that the case has been accepted and that Mr. Henry Barbour has been assigned to this complaint. It is my understanding that he will be in touch with your office no later that April 8, 1996. I have also requested that my attorney be prepared to file a civil action against NCH Healthcare System should the outstanding BID be offered to any firm that does not have the qualifications and medical experience that would be in compliance with Federal Law. You should also be aware that the remedies I am seeking are as follows: 1. Enforcement of 45 Code of Federal Regulations 80.8(a)(1989). 2. Civil fines. 3. Civil action by the DHHS Office for Civil Rights. For whatever reason senior members of NCH Healthcare System staff have tried to deny the provision of Professional Medical Interpreters for it's patients. If you have any questions I can be contacted during business hours. Yours faithfully, by-fax James H. King cc. Dq:.l ofHea1th and Hwnan Services, Office fOl" Civil RiWtts "''''''~'''''_'''''''''''''''''i'. ".."-'1,...., MEDICAL INTERPRETERS P.O. Box 9745 Naples, Fl., 33941 (941) 566-3720 Mrs. Marie Chretien Regional Manager Office for Civil Rights DHHS, Region IV 101 Marietta Tower, Suite 1502 Atlanta, GA., 30323 4/1/96 Dear Mrs. Chretien, The following is a brief history of my association with NCH Healthcare System. Just over six years ago ] met with the Director of Nursing, Kathy Getz, and discussed the possibility of providing professional Medical hrterpreters to NCH Healthcare System. ] was advised that, for the most part, there was no reimbursement for interpreters service and that NCH Healthcare System would not cover any such costs. ] advised Mrs. Getz that if] could be assured of providing service to most of their Workers' Compensation and Motor Vehicle patients' ] would be willing to provide service to all others without charge to NCH Healthcare System. Over the years] have provided this service on a 24 hour a day, 7 days a week basis covering 5 major languages. NCH Healthcare System has fought this service from the point of administration, however, the working staff love and respect the service] have provided. Administration has tried to force staff to use A. T & T. operators, or people from the lobby before calling Medical Interpreters. During the last six years Medical Interpreters has never received any payment, direct or indirect, from NCH Healthcare System. In 1995 Medical hrterpreters was called by NCH Healthcare System to provide Medical hrterpreters over 2,000 times. All staff at Medical hrterpreters have some form of medical degree. All staff at Medical hrterpreters have completed a Medical and Emergency Medical Language class and training program. Medical hrterpreters only provides Medical Language service and has never provided service to any other business or entity whatsoever. When NCH Healthcare System became aware that 1 was looking to file with your office they sent out a Request for Proposal Bid for "Translators". NCH Healthcare System is looking to have a firm without any medical experience provide this service. ] believe that when a service such as ours exists the provision of any other kind of service is an active form of discrimination by the facility against the patient. ,..."....,.. On or about April 5, 1996 NCH Hea1thcare System is looking to award a contract for "Translators". I believe that they should be put on notice about the possible violations of this action until such time as your office has the opportunity to review my complaint against NCH Hea1thcare System. I would be very grateful for your input on this matter. Yours faithfully, by-fax James H. King Special Communication Language Barriers in Medicine in the United States S:eV2n I;Voicsriln, ;\/10: ,\Jlna A. BickelL ;\;ID. \IPH. i_lsa M Scr:'.vanz, MO ,;:ra,'''cesca Ga,~.y, ;\;10: H. Giloe...: \Velc"", \;10, "'I1PH ~Vhat the scalpel is to the s'1.~rgeoi'1.. words are to the cli'nician . . . the con-u8nation oeh(:een doctor and pat-ient is the heart of the pract-ice of medicine,l T11e physician-pat:ent relationship is Juilt through communication and :he ef- fective ~lse of language, Along\\ith clini- cal reasoning, observations, and nonver- oal cues, skillful use of language endows tbe histor'y i\ith tts clinical power and establishes the medical intervie''v as the clinician's most powerful tooL~~ Lan- guage [s che mea~s by \-vhieh a physician accesses a patient's oeliefs about :-:.ealth and illne::3s," ':::l'ea:ing an opportunity :0 address and reconcile different beliefsvs- terns. Fur:hennore, it is ~hrough l~n- gnage L'i.at ;:Jnysicians and patients :J.chieve an emnathic connect:on batmav oe ::lerapeuL~ in :tselC;- ~ Becanse aflangt..lage oal'1i~l's, f.'1ilEons of US ~'esider.ts cannot hase this con- nection \\,ith ~heir physician. According co the 1990 1.,-S Census,s almost 14 mil- lion people living in the "United States de r.ot ha ve good English-language .skills, \\-nile thi3 population is mainly concen- trated in the ;arge, urban centers, sig- nincam numoers of immigrants and refu- ;!ees ',vicD lir:1ited Eng-:ish proriciency are found throughout the Un{ted Stat.e;. C'Limited English proficient" is the tenn u.sed by the US Depar:mem of Health :='C,'~ Ire 'JS;::3r:m:!r::)1 '/;Jler2.rlS ..l.,::.:!irs 1'/e::JI::.:!i CBn:'?',;\;~::e ::;"Jer JL..,1::.0,1, 'It :D,'$ 'i'iacshn 3C:1'I.'3~'Z 3.rc ";....elcr) t~e ::"'/IS:O'1 c' ?:':~3r'! Care: r.jaw '!;elk ,,\,v: ',,:live:sitv SC'1::ai ,:1 !vledicire ~Crs =,c~eil a,l::J ':;"''-'1':', 1rc :.''''e ::a,~,[e: Icr :,1i! c'.'alL...s.ti'le ::: rea; Sc,ence5, Ci'.:I.~;:E.i11 Meai::! Sc~co~. c-iJr, :;'/2:. 'JH ':::" '"je'cl~ :::::. :k:k".'lI ,s rew 1 3e1ij. ~ec, :1; :%23/C,1 S.: 31:s1.'lItr :ra ::::li<::8 :)~ '::"..:alliyi'"- ::wJ'Je~e1f. :~e'iI 'lor\; Sla:e Cepar:mer: d rea!:r ~ep"I,'1: :e:::;t.S<$ts :c '/A 8vccrr,es G::u ,;' ~8~ G,002.r'fT,er: ,::;: '/;:e'3rs ;.,fL3;rs ,'viedi::al Cen:e:', iI1i'.~ ?i'le: J:...re:i:J;~. ',-:: C.58C9 ',J' '.";'OIOSr::,) 724 ';ii.,1V1A, :vlerc~ ~ 1395-V,)1 273. ;\0. 9 and Human Services [DHHSJ Office for Civil R~ghts to define ~he portion of the population that is non-English speak- ing or liT:1ited-Eng!:sh speaking.) ~Iore t;lan 10% of che population in five states (Califonua, :\~ew York, Texas, New 1Iexico, and Ha\-vaii) haye limited En- glish skills.3 For these people, language can be a formidable harder to accessing a:r.d receiving health care.l~ The use or' interDl'eters is ~he standard solution CO language oarriers. Herein, we re'lie\v the CLll'l'ent status of inter'preter services in the CS :1ealth care svste!TI the clinical impact. of inadequate~ int(~r~ pl'etation, and the legislative responses :0 the language needs of patient.s \vith limited English proficiency. THE USE OF INTERPRETERS Professional interpretation is a com- monly used service ir: intemational busi- ness and diplomacy. Dome~ticallr, pro~ ,'essional interpreters enable defendants ~\-ith limited English to participate mean- ing;:'ully in t;,e legal process and are re- quired by lal,v in the :edel'aj cow'"::s.:! Professional interi.)re:e~'s a.re formall\' :rained and demo~s::ratc a high degr~~ of pronciency in mediating communica- tion ber:'.veen languages. ~'eliably mini- mizir.g the effects O[ !:mguage dif:er", enceY W"hile common in othe~'er:',"ir0nment5, pror'essional inter::Jreten are 1':',-1'elv available in :-:ealth care. ~-e'.v Yark Cit';, which has one of che largest Iimited- English-speaking populations in the country, does not employ pror'essional medical interpreters in its public h03- pita! systerr:, Instead, as in most or the enited States, patients and cli::dcians rely on one 'Jr' three suboDtimal mecna4 nisms: (1) :heir own langUage skills, (2) the skills of family or friends, or (3) ad hoc interpreters (bilingual strangers from the ',vaiting room, or employees like a clerk. aide, OJ' custodian called away from regular job ~'esponsibilities to be an interpreter). Each rr.echanism has weakilesses. :VIost US physicians are probably not sufficiently bilingual to practice in a lan- guage other than English. In busy clin- ics, '.vhen rinding an interpreter is dif4 ficult or ~lean8 long delays, physicians 01' patie~t.:; may attemp:: to communi- cate by using inadequate language skills. T~is may compromise information Cl'ans- fer 8.11d rn.ay distract -.:he physician's intellectual focus J\vay from clinical chinking. Equal1y important, lang'llage harTiers can lead to a frustrating en- counter for both onvsician and Datient. Family, n~ends: ~d ad hoc in:erpret- ers pose problems. They :nay lack suffi- ciently good language skills <l!ld t1'Bq'.lently commit st2reoty-pical et1-'ors, i-r.duding cmissio-r.s, additions, substitutior:s, or othel- editing, which maj' !'esult ir: serious semantic riistortions,3-1S and negatively affect C3.l'e. ::i,:":' In one observational stud::,', analvsis of recorded ad hoc imerDrpte"- 2..5si;ted encounters demollstrat~d ~:h;t 23% to 52% of words and onl'ases ',rere mco17ec+Jv :ranslated. ~3 Oth~'reasons use of 3d hoc !nterpl'etel's mlt:,' not be appro'" plia~e ;r:cluue :he possibilit:y that they may not be fully committed :0 providing quality imerpretat:on because it ;nay oe viewed as arc uI1\velcome, ~npaid burden. Eequesting :he assistance of ad hoc in- terprete~'.s, ;Ja.rticularly frt."Tlily 01' :11encis, al.so may uYldermine patient confidenti- U'-';Juage 8e;,"ers', Iv!e::::re--Wc!cs.,n et a! ality, Using children to interpret may po- tentially expose them to sensitive infor~ mation and invert family dynamics. By contrast, a number of interpretet orga- nIZations have established u2'ofessional codes of conduct adcb'essing'issues such as ensuring client confidentiality,:~ CLINICAl. CONSEQUENCES OF INADEQUATE INTERPRETATION Language barriers impair the ex- change oflnformation from patient to physician.I::-l~,l~,20,21 Loss of the usuallin- guistic cues may disrupt how physlcians assess and evaluate symptoms and te4 sult in misdiagnoses. l3,22 Compromising (he diagnostic po\\'er of the intervie.......- may make physicians more depe~dent on diagnostic tests or, in some cases, missing important cues, less likely r.o order needed tests. l"nnecessary test- ing is expensive and inconvenient and may expose patients to the lisks of false4 posith-e results. Furthermore, under- standing a patient's culturally deter~ mined disease model can be crucial to providing good care, Physicians with- out competent interpreter services may never get beyond the language banier and lose access to important cl'oss-cul- tura! information, Language ban'jers also can impair communication from physician to patient. If patient education occurs at all, it may be incomplete. Ifpatients misunderstand instructions, the care that is proposed may be undermined. Patients who have limited English proficiency may find vis4 its difficult, particularly if complaints, questions, or psychosocial concerns can. not be addressed effectively. If family members or strangers from the \vaibng room are called on to interpret, patients may feel inhibited, emba11'assed, or an- gry, Dissatisfied patients may avoid rou- tine care or delay seeking needed care and enter the system at a more advanced 5tage of di5ease. The result of language ba!Tiers is often poor compliance,13 in- appropriate follow-up,2J and patient dis~ satisfaction. 10.2':.25 Inadequate interpretation also raises. important ethical problems, Infonned consent is an ethical obligation, \vhich is fundamental to the physician4patient 1'e- lationshi'J.2~ Consent obtained across a language' barrier without competent in- cerpretation is unlikely to be tnl!Y in- formed, Similarly, because patients who cannot be undel'stood are unabLe to oar- ticipate meaningfully in personal ~are decisions, inadequate interpretation un- dermines shared decision ma.king, This violates patient autonomy and imposes a patemalistic stance on the physician, Since patient autonomy is a basic plin- ciple in 'VVestern medical decision mak- ing and practice,2";, adequate comrnuni- ..iA[vlA,. ~,'iar::" 1, . 995 VOl ;:'73, 1,1f), '3 cation is a. prerequisite of ethical medi- cal practice. Finally, language affects access to care. Patients wii:hout good English skills may' have t~'ouble accessing medi- cal services,!8 !'esulting in less use of both acute carelO':::?.3Q and preventive se1'- vices.10,~1,J2 THE CIVIl. RIGHTS ACT OF 1964 AND SUBSEQUENT FEDERAl. POI.ICY The DHHS Office for Civil Rights views inadequate interpretation as a form of discrimination. This view has its Oligin in the Civil Rights Act of 1964. which scates chat ;'no oersoCl in the Cnited States 5haJl, on 'the ground of race, color, or :1ational origin be excluded from participation in. be denied the ben- e~its of, or be othenvise subjected to discrimination"33 uncle!' any :'ederally supported program. The Offiee for Civil Rtghcs chen extended this protection to language, considering it to be a unique and fundamental chal'acteri.st:c of na- tional origin, This defipition \vas origi~ nally rendered to ensure equai educa~ bonal access for children \\ith limited English proficiency and was upheld by the Supreme Court in 1974.'~ The office also requires DHHS-funded health pro- grams to provide patients \\,ith limited English skills access to services equal to those provided to English speakers.~5-3~ Programs that do not comply ri.sk loss of all federal funds, including :'vIedieare and Medicaid paymems,3~ Ho\vever, the cun'ent regulation has three problems. First, the regulation is vague, At the national level, the Office for Civil Rights provides no guidance for hov; to detel":nine the adequacy of interpretation, how ':0 assess bilingual- ity of staff, or \'I.'hat constitutes a com- petent medical imel1Jl'eter, Some guid- ance is offered, hO'.vever. oy a few re- gional offices. The Region X office in Seattle, ,"Vash, issued a g-uideline for ef- fective communication that discourages inteq)reting by family OJ: fr:ends and urges ad hoc use of only "truly bilingual staff' (these able to comrnu!1icate with equal skill in both languages about the health care services orovided),'IOThe Re- gion IX office in S~n F'rancisco, Calif, requires facilities to "assure that all per- 5005 who get{or:n interpreter functions, regardless of \vhether the)' are staff members, famil,y membel's or fr:ends, or professionat 01' community resources, . possess adeauate skills to effect:velv communicate'betv.,'een patient and health care staff."~: Second, funds to implement the regu- lation are inadequate, Medicare policies consider bilingual services reimbursable costs for hospitals, including "the costs of translators, , . and speciai personnel recrllitment efforts designed to recruit bilingual employees:"':2 But no explicit billing for interpreter services is allowed; monies are instead included in hosoital overhead rates, Provision to pay for'out- patient inteqn'ete1' services does not eX4 ist_ 1Iedicaid policies vazy among the state:::, Typically, hospitals are reim4 bursed in the form of "service cos.ts" built into the rates ror items like elec4 tl'oca1'diograms or laboratory tests (writ~ ten communication, Lon Schiro, direc- tor, ::\Iedicaid OperatoDs Bro.i1ch, :\' ew York. -"Y.January 1994). In 1993, Wash- ington became the only state to create a separate billing code for imerpl'eta- tion.;3 Because both federal programs are under increasing pressure to limit their budgetary gTowth, finding a way to pay for bilingual services will be a challene-e, Third, the cunent regulation relies on ad hoc enforcement. Because of staff and resource shortages (a staff of 300 oversees 100000 organizations receiv- ing DHHS funds), the Oftioe for Civil Rights' compliance monitoring system is essentially complaint driven.~.j Some complaints have resulted in positive rem~ edies, including allegations of inadequate language services chat were filed in Se- attle!';";,~li San F'l'aneiscoY and Chicago, IlL~8.J9 However, a complaint-driven enforcement system is likely to under- estimate problems. In particular, the populations most likely to suffer such discrimination (eg, recent immigrants, including undocumented aliens) are of- ten unaware of their rights and fear governmental reprisals if they complain. OTHER I.AWS Failure to communicate adequately was determined to be the source ofneg- ligence in several relevant tort law cases. \vlUle these cases are more than 25 veal'S old,:;o they could be applied to cU;Tent cases of inadequate interpretation. Since it is the physician's duty to perform a propel' medical interview, the failure to do so can constitute neglig.ence for \vhich the physician may be held liable if the patient suffers some subsequent injury athibutable to this failure. Thus, que~- tions about the accuracy or complete4 nes"S of medica! histories obtained across language barriers \vithout interpreters (or interpreters of unknown quality) raise concerns about potential malprac4 tice litigation, The same problem may apply to informed consent, in which the validity of consent obtained across a lan- guage vbarrier could be subject to legal challenge. 110st states do not have legislation explicitly dealing with interpreter ser- vices. The majority of those states that Largu3ge Barriers in IvIGdicine-Wo~oshG e: a' 725