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Executive SummaryBackgroundFundamental ethical aspects of healthcare between providers and patients arecompromised when people who have not received healthcare interpretertraining are asked to interpret. These include, among others, the loss ofconfidentiality, potential misdiagnosis, and potential invalid informedconsent. These consequences increase healthcare costs and liability, and lead topoor health outcomes (we have a substantial reference section citingnumerous studies, reports and earlier standards documents to make our case).There is a misconception that bilingual individuals without training canprovide adequate interpreting. Unfortunately, the parties most affected by theinterpreting lack the skills to judge its quality. They assume the personproviding the interpreting is doing an adequate job. This may create amisplaced sense of security that effective communication is taking place.The creation of the CHIA standards was a complex process involving ongoingfeedback from healthcare interpreters, including four formal focus groups incenters across California. The Standards and Certification Committee beganits work in January 2001, with a review and synthesis of earlier standards ofpractice. In producing these standards, CHIA has based its work on bothresearch and practice described in the current literature of the variousacademic fields, as well as healthcare interpreter training literature.This document was written and produced by the Standards & CertificationCommittee of the California Healthcare Interpreters Association (CHIA)through a grant from The California Endowment. The co-authors (members)of the Standard & Certification Committee are: Ann Chun, M.P.A., Co-Chair,Alameda County Children & Families Commission; Elizabeth Nguyen, CoChair, L.A. Care Health Plan; Niels Agger-Gupta, Ph.D. Consultant, formerCHIA Executive Director; Claudia Angelelli, Ph.D., San Diego StateUniversity; Carola E. Green, Vista Community Clinic; Linda Haffner, formerCHIA President (1998-2001); Marilyn Mochel, R.N., Healthy HouseAnnex/California Health Collaborative; Linda Okahara, Asian HealthServices, Oakland; Beatriz Solís, M.P.H., LA Care Health Plan; and GayleTang, M.S.N., R.N., Kaiser Permanente, Program Office, Oakland.9

Executive SummaryOverviewThe document’s three main sections guide interpreters through the complextasks of healthcare interpreting. Interpreter training will be essential to helpinterpreters put into practice the ethical principles in Section 1, the protocolsin Section 2, and the complex roles outlined in Section 3. The view reflectedthroughout this document is that healthcare interpreters, as members of theteam of healthcare professionals working with the patient, have aresponsibility to support the health and well-being of patients.Section 1Section 1 consists of the ethical principles that guide the actions of healthcareinterpreters. Each ethical principle has an underlying value descriptionfollowed by a set of performance measures which demonstrate how theinterpreter’s actions follow the principle. The principles are followed by asection on an ethical decision-making process to help interpreters address thefrequent ethical conflicts and dilemmas that arise for interpreters. Dilemmasoccur when any action in support of one or more ethical principles conflictswith one or more other ethical principles. This process is also helpful formaking decisions about interpreter roles.Each of the following ethical principles is to be considered in the context of thehealth and well-being of the patient.1.ConfidentialityInterpreters treat all information learned during the interpreting asconfidential.2. ImpartialityInterpreters are aware of the need to identify any potential or actual10

Executive Summaryconflicts of interest, as well as any personal judgments, values, beliefs oropinions that may lead to preferential behavior or bias affecting thequality and accuracy of the interpreting performance.3. Respect for individuals and their communitiesInterpreters strive to support mutually respectful relationships betweenall three parties in the interaction (patient, provider and interpreter),while supporting the health and well being of the patient as the highestpriority of all healthcare professionals.4. Professionalism and integrityInterpreters conduct themselves in a manner consistent with theprofessional standards and ethical principles of the healthcareinterpreting profession.5. Accuracy and completenessInterpreters transmit the content, spirit and cultural context of theoriginal message into the target language, making it possible for patientand provider to communicate effectively.6. Cultural responsivenessInterpreters seek to understand how diversity and cultural similaritiesand differences have a fundamental impact on the healthcare encounter.Interpreters play a critical role in identifying cultural issues andconsidering how and when to move to a cultural clarifier role.Developing cultural sensitivity and cultural responsiveness is a life-longprocess that begins with an introspective look at oneself.We believe the addition of an ethical decision-making process for healthcareinterpreters is a critical contribution. These steps assist interpreters indetermining a course of action in ethical dilemmas, when actions to supportone or more ethical principles may conflict with one or more other ethicalprinciples. Appendix B gives an example of how this ethical decision-makingprocess is used in practice. The steps to the process are:11

Executive Summary1. Ask questions to determine whether there is a problem.2. Identify and clearly state the problem, considering the ethical principles thatmay apply and ranking them in applicability.3. Clarify personal values as they relate to the problem.4. Consider alternative actions, including benefits and risks.5. Choose the action and carry it out.6. Evaluate the outcome and consider what might be done differently nexttime.Section 2Section 2 describes procedures standardizing how interpreters work withpatients and providers in the healthcare encounter before, during and aftertheir interaction or session. The protocols specifying interpreter actions areseen as a direct consequence of the Ethical Principles. This section alsoincludes recommendations to the employers of interpreters on how to providesupport to healthcare interpreters in their often stressful work.Protocol 1: Pre-Encounter, Pre-Session, or Pre-InterviewThis protocol outlines information interpreters should provide in presession introductions to assure confidentiality and gain the cooperationof patient and providers for a smooth interpreted encounter. Theprotocol also allows for a pre-encounter briefing of the interpreter orprovider as necessary.Protocol 2: During the Encounter, Session, or InterviewInterpreting practices to support the patient-provider relationshipduring the medical encounter are presented in this section. This includesencouraging direct patient-provider communication through practicessuch as positioning, verbal reminders or gesturing for patient andproviders to address each other directly, and use of first personinterpreting. This protocol addresses the need to manage the flow of12

Executive Summarycommunication and facilitate or seek clarification of messages as well ashow to conduct more active interventions when necessary. This sectionalso flags the importance of interpreters to clearly identify when theyintervene and speak on their own behalf, and describes how this may bedone.Protocol 3: Post-Encounter, Post-Session or Post-InterviewThis protocol addresses steps interpreters take to provide closure to theinterpreted session. This ranges from ensuring that the encounter hasended and no other questions or concerns are outstanding, to facilitatingfollow-up appointments and scheduling of interpreter services, asnecessary, and debriefing with the provider or interpreter’s supervisor asneeded.Section 3Section 3 identifies communication barriers LEP patients experience in thehealthcare setting. CHIA recognizes these barriers create a need for multipleroles for healthcare interpreters. This section defines these multiple roles anddescribes performance strategies to facilitate communication and assist theinterpreter to set appropriate boundaries for the benefit of all parties in anencounter.Four roles are discussed:1. Message ConverterIn this role, interpreters listen, observe body language, and convert themeaning of all messages from one language to another withoutunnecessary additions, deletions, or changes in meaning.2. Message ClarifierIn this role, interpreters are alert for possible words or concepts thatmight lead to misunderstanding and identify and assist in clarifyingpossible sources of confusion for the patient, provider, or interpreter.13

Executive Summary3. Cultural ClarifierThe cultural clarifier roles goes beyond message clarification to includea range of actions that typically relate to an interpreter’s ultimatepurpose of facilitating communication between parties not sharing acommon culture. Interpreters are alert to cultural words or conceptsthat might lead to misunderstanding and act to identify and assist theparties to clarify culturally-specific ideas.4. Patient AdvocateIn this role, interpreters actively support change in the interest of patienthealth and well-being. Interpreters require a clear rationale for the needto advocate on behalf of patients, and we suggest the use of the ethicaldecision-making process to facilitate this decision.We stress that the complex patient advocate role is an optional role which mustbe left to the careful judgment of trained, experienced interpreters to decidewhether to pursue in a given situation. The patient advocate role has notpreviously been clearly defined, and the guidelines here are intended to assistinterpreters better understand the ethical thinking process required andsuggest appropriate actions for this role. We anticipate feedback and suggest anethical advisory committee be established to provide feedback on case studies.AppendicesThe last section contains appendices. Appendix A includes a brief overview oflanguage barriers and health outcomes; Appendix B, an example of an ethicaldilemma and the application of the ethical decision-making process;Appendix C, a discussion of group advocacy (outside of the role of theindividual interpreter); Appendix D, a glossary of bolded and italicized wordsused throughout the document; and Appendix E, references for all citations.14

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IntroductionThe 2000 federal census shows that about 224 different languages arespoken in California. The largest non-English language group, Spanishspeaking Latinos, is one-third of the population of California. They willprovide 60% of new growth in California’s population between 1990 and 2010(Forum, 1997). The Asian-Pacific Islander population in San Franciscooutnumbers whites (Forum, 1997).According to the Centers for Disease Control and Prevention, 77.8% ofLatinos in the United States speak a language other than English. Of these, 39.4percent do not speak English “very well.” Similarly, 73.3% of Asian/PacificIslanders speak a language other than English, and 38.4% do not speak English“very well” (Centers for Disease Control and Prevention, 1998).The impact of these demographic changes is increasingly experiencedthroughout all aspects of U.S. society, especially in the delivery of healthcareservices. Since communication is fundamental to the relationship betweenhealthcare providers 1 and patients, language is therefore, “one of the mostformidable obstacles to healthcare access by members of ethnoculturalcommunities” (Torres, 1998; Wirthlin Worldwide, 2001; Woloshin, Bickell,Schwartz, Gany, & Welch, 1995.)216

IntroductionThis Standards document was designed for a number of target audiences:healthcare interpreters, bilingual workers, administrators, providers,interpreter trainers, community advocates, legislators and governmentagencies, foundations, policy-makers, and researchers and others in theacademic community. The goal of this document is to set standards for thepractice of healthcare interpreting. Our hope is that a consistent and moreprofessional healthcare interpreting profession will result in improved accessto healthcare services for Limited-English Proficient (LEP) patients.Making the Case for Professionally TrainedHealthcare Interpreters and Standards of PracticeHistorically, the task of interpreting for patients who speak limited English(LEP) was delegated to any available self-declared bilingual individual present,regardless of their actual language ability or relationship to the patient. Ad hocuntrained interpreters typically include family members of the patient,including children; volunteers from other parts of the health organization; orany other individuals from the cultural/linguistic community of the patientwho happen to be available on-site or available by telephone.Even when ad-hoc interpreters may be ready to step in, asking people whohave not received healthcare interpreter training to perform this taskcompromises some fundamental ethical aspects of healthcare betweenproviders and patients. These include, among others, the loss ofconfidentiality, potential misdiagnosis, and invalid informed consent. Theseconsequences increase healthcare costs and liability, and lead to poor healthoutcomes (Garber, 2000; Massachusetts Medical Interpreters Association &Education Development Center, 1995; Office of Diversity Mount St. JosephHospital, 1996; Pollard et. al., 1997; Roat et. al., 1999; ASTM, 2000; WorkingGroup of Minnesota Interpreter Standards Advisory Committee, 1998).17

IntroductionThere is a misconception that bilingual individuals without training canprovide adequate interpreting. Unfortunately, the parties most affected by theinterpreting lack the skills to judge its quality. They assume the personproviding the interpreting is doing an adequate job. This may create amisplaced sense of security that effective communication is taking place.Establishing a consistent set of interpreter standards of practice by whichinterpreting services may be measured is important for patient health servicesdelivery. These standards may then be used for a variety of purposes, includingtraining, job descriptions, performance evaluation, and may eventuallybecome the basis of interpreter certification.Healthcare Interpreting in CaliforniaTitle VI of the Civil Rights Act of 1964 establishes the need for professionalhealthcare interpreters to ensure meaningful access to healthcare for LEPpatients. The Policy Guidance issued by the Office for Civil Rights in 2000provides the strategies to help healthcare organizations meet their obligationsfor culturally and linguistically appropriate services.3California also has a variety of legislative requirements calling for the use ofinterpreters (California State Assembly, 1973, 1975, 1983). Some hospitalsacross California developed interpreting services, sometimes as the result of alawsuit, a critical patient-care incident, or a desire to improve their services.But hospitals do not have consistency in how interpreters are screened, tested,trained and evaluated. A set of standards is needed to provide consistencyamong all sites and to establish consistent performance expectations for allinterpreters.In 1996, a group of interpreters and interpreter service managers from the keyhospitals in the Bay Area and the Los Angeles region founded the CaliforniaHealthcare Interpreters Association (CHIA). They recognized the imperativeneed to collaborate in order to support the development and training of18

Introductionquality healthcare interpreters, as well as the need for establishing healthcareinterpreting as a profession. CHIA envisions a time when all interpreters andproviders across the state agree to work from the same set of expectations andethical standards.CHIA Standards of PracticeThe creation of the CHIA standards was a complex process involving ongoingfeedback from healthcare interpreters across California. The Standards andCertification Committee began its work in January 2001. The first step was toreview and synthesize standards of practice existing at the time (Garber, 2000;Massachusetts Medical Interpreters Association & Education DevelopmentCenter, 1995; Office of Diversity Mount St. Joseph Hospital, 1996; Roat et. al.,1999; ASTM, 2000; Working Group of Minnesota Interpreter StandardsAdvisory Committee, 1998). In producing these standards, CHIA has based itswork on both research and practice described in the current literature of thevarious academic fields, as well as healthcare interpreter training literat

CHIA is grateful to The California Endowment for embracing our vision of trained, professional healthcare interpreting, and providing CHIA with the . administrators and language access supporters across California and the USA, who have commented on earlier drafts, participated in CHIA chapter . James CarmazziTreasurer, Carmazzi & Associates .