Transcript Managing an Interpreting Encounter

For Healthcare
Interpreters: Short Review of
Ethics, Standards, Roles, Legislation and
Regulations, and Terminology Tips
--Or, getting yourself ready for Part 1 of
either national certification test
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Two organizations offer a
nationally recognized certification
test: CCHI and NBCMI
http://www.cchicertification.org/
http://www.certifiedmedicalinterpreters.org/
3
About the two tests:
Both groups did
surveys and based their test content on their respective
interpreter responses.
The text below is copied from the comparison chart created by Elsa Boyer.
NBCMI
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Roles of the Medical Interpreter
(8%)
Medical Interpreter Ethics (15%)
Cultural Competence (8%)
Medical Terminology in Working
Languages (38%)
Medical Specialties in Working
Languages (23%)
Interpreter Standards of Practice
(IMIA, CHIA, NCIHC) (5%)
Legislation and Regulations
(HIPAA, CLAS) (3%)
CCHI
•
Manage an Interpreter Encounter
30-35%
• Healthcare Terminology 22-25%
• Interact with Other Healthcare
Professionals 20-24%
• Prepare for an Interpreting
Encounter 16-20%
• Demonstrate Cultural
Responsiveness 3-6%
For more detail, go to
http://www.cchicertification.org/i
mages/pdfs/testoutline.pdf
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Visit both websites
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2014
Both groups offer materials to help you
prepare for testing including handbooks that
you can download, webinars (some are past
recordings) and newsletters.
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Credit where credit is due:
For this short class, I followed the lists of topics for both tests, selecting material from a
40-hr course developed at L.A. Care Health Plan (a course I taught more than a dozen
times from 2005 to 2008) and the publications of the three nationally recognized
organizations that have published ethics and standards for healthcare interpreters:
CHIA, IMIA and NCIHC.
California Healthcare Interpreting Association www.chiaonline.org
International Medical Interpreters Association www.imiaweb.org/
National Council on Interpreting in Health Care www.ncihc.org.
I include some slides that I credit to other interpreter trainers.
The California Endowment supported the work of many of the organizations and
projects that helped to shape the field. Such content is in the public domain.
And last, but not least, on several slides, I refer to chapters (specifically Chapters 4 and
10) from Healthcare Interpreting In Small Bites, 50 Nourishing Selections from the
“Pacific Interpreters Newsletter,” by Cynthia E. Roat. To purchase a copy, go to
http://cindyroat.com/
Beverly Treumann, CHITM, CMI
2014
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Learning Objectives:
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Recall concepts from introductory courses in
healthcare interpreting that are fundamental such as
the purpose of the pre-session, how and when to
intervene to support effective communication, and
the meaning of the principle of transparency;
Define ethics, standards, roles and other terms of
art for the interpreting profession;
Recognize the laws and regulations that inform
language access practices and policies in healthcare;
and
Identify ways to improve your command of medical
terminology.
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Managing an Interpreting
Encounter?
Is that part of the
Interpreter Role?
30-35% CoreCHI
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Yes.
At one time, many people believed that the
interpreter was like a robot.
Message in. Message out.
Voila! Communication succeeds across a
language barrier!
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But providers and patients do not
speak consistently in clear, short
statements.
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If people spoke clearly all the time, we would
probably have no comedy TV. Aren’t most
TV comedies about misunderstandings that
happen in everyday life? And all in the same
language?
Why did anyone ever imagine that
interpreting in healthcare was just message
in, message out?
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Over the past 15 years or so, many
concepts that are better than the
robot image have been articulated by
interpreters themselves. These have
been formalized by academics and by
interpreter organizations.
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Incremental model of intervention and was
first developed by Cynthia Roat.
Interpreter roles
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Roles
Patient Advocacy – like fats and
sweets in the old food pyramid: use
sparingly.
Roles as listed in
the CHIA
Standards. Other
writers and
publications,
Cultural Clarifier
including Roat,
list “cultural
broker” instead of
“cultural
Message Clarifier
clarifier.”
Message Converter (KP & other
material: “conduit”)
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Tip: view video on roles
at
http://www.ccsf.edu/en/
educationalprograms/school-anddepartments/school-ofhealth-and-physicaleducation/healtheducation-andcommunity-healthstudies0/HCIcertificate.
html
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Roles Presented at a 2003 CHIA conference:
“The Healthcare Interpreting Ladder”
FRAME:
PATIENT ADVOCATE
(Professionalization
of Healthcare
Interpreting)
Systemic Barriers
CULTURAL CLARIFIER
•CHIA
•Testing
Culture Barriers
•Language Training
MESSAGE CLARIFIER
•CEUs
•Organizational
Policies
Register Barriers
•Job Descriptions
•Certification
MESSAGE CONVERTER
Language Barriers
PRE-SESSION – 1ST PERSON - POSITIONING
HEALTHCARE
INTERPRETERS:
• go up & down the
steps of the ladder,
• move in & out of
roles
• sometimes having
each foot on a
separate step,
playing multiple
roles
simultaneously
(Risky and
complicated!)
ADVANCED TO SUPERIOR BILINGUAL PROFICIENCY
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Developed by Marilyn Mochel, RN; Healthy
InterpreterHouse
NetworkWithin a MATCH Coalition; Merced, CA
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Patient Advocacy
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When the patient’s health, well-being, or dignity is
at risk, the interpreter may be justified in acting as
an advocate.
Advocacy is understood as an action taken on behalf
on an individual that goes beyond facilitating
communication, with the intention of supporting
good health outcomes. Advocacy must only be
undertaken after careful and thoughtful analysis of
the situation and if other less intrusive actions have
not resolved the problem.
Tip: Read Chapter 10,
From National Code of Ethics for Interpreters in Health Care.
2014
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Interpreter as
Advocate, of
Healthcare Interpreting
in Small Bites
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To move between roles, we may
intervene
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1. Message Converter Role
We go back and forth in “first person.”
If we don’t hear or remember, we might say “As the
interpreter, may I ask that you repeat.”
2. Message Clarifier Quick example: “‘Pink eye,’ as
the interpreter, may I ask, do you mean
conjunctivitis?”
3. Cultural Clarifier quick example: A mother of a
child on dialysis says “Mi hijo se está poniendo
gordo.” The social worker understands one word as
a criticism: “fat.”
4. Patient Advocate “Next time, bring your own
interpreter..”
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When to intervene: Common
problems in message converting
The speaker speaks too fast or too
softly or does not pause for you to
interpret.
 Someone interrupts you and does
not let you finish interpreting.
 Too many people speak at the same
time.
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When to intervene: Common
problems in message clarifying
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Register
Lack of linguistic equivalence, managed care terms
Idiomatic phrases
When you, the interpreter, don’t understand.
When you do understand, but…you have reasons
to think that the listener may not have understood
the speaker. You want to check for understanding.
When you need to clarify the meaning of a
concept that may be understood differently by the
patient and the provider. Example: alergia, pie,
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Intervene to cultural clarify
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You need to clarify a cultural concept that you
suspect may have caused confusion or
misunderstanding
fat
sushi
yin and yang risk
Intervene – patient advocacy
A patient is being denied service he or she is entitled to
receive. A patient is being given a service that is of a lower
quality than what an English-speaker would receive.
Examples:
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How to intervene:
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Signal
that you will stop interpreting (speak or gesture)
Or, use your words (transparency)
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Identify your voice as your own.
Say it in both languages.
Refer to yourself as “the interpreter” while
intervening.
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Explain …to BOTH parties the reasons why you
are intervening, so that everyone understands.
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Goal is
Get in. Get out!
Once you’re done intervening,
quickly go back to the message
converter role.
 These steps help you avoid having a
side conversation with one party,
while the other party is left out and
does not know what is happening.
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Transparency Means Clarity
Chapter 4, Transparency Means Clarity, of Healthcare Interpreting in Small Bites, by Cynthia Roat
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1) Transparency means an interpreter who is accurate
and complete will interpret everything that is said.
2) When there is confusion the interpreter may intervene
for misunderstandings, cultural issue, a repeat, or a
pause.
3) Being transparent means that if you have a valid
reason to talk to one party, tell the other party what you
will do.
4) Being transparent means everyone knows what is
being said.
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Transparency means boundaries
in NCIHC doc.
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To maintain professional boundaries means
that interpreters fulfill only the duties of a
health care interpreter while engaged in the
performance of that role and do not assume
any duties that are outside that role.
(Relates to ethic as listed by NCIHC: The interpreter maintains
the boundaries of the professional role, refraining from personal
involvement. The intent of this principle is twofold: 1) to provide
transparency in the service that is being provided, and 2) to
avoid potential conflicts of interest.)
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Definition of transparency from
National Council on Interpreting in
Health Care.
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The principle that during the encounter the
interpreter informs all parties of any action
he or she takes, including speaking for himor herself, outside of direct interpreting.
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As healthcare interpreters
began to make new rules, it
became necessary to explain
our rules to others. My anecdote: no le

entiendo a ella para
nada.
The pre-session
a) introduce yourself
HCIN Greeting is based on the Pre-Session as described in the
CHIA Standards: “Hello my name is XXX, Spanish
interpreter XX###. How may I help you?
b) confidentiality
c) everything will be said
d) recommend that parties speak directly and pause frequently
e) explain that you may need to intervene
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NCIHC Code of Ethics
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The interpreter treats as confidential, within the
treating team, all information learned in the
performance of their professional duties, while
observing relevant requirements regarding
disclosure.
The interpreter strives to render the message
accurately, conveying the content and spirit of
the original message, taking into consideration
its cultural content.
The interpreter strives to maintain impartiality
and refrains from counseling, advising or
projecting personal biases or beliefs.
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NCIHC Code of Ethics, continued
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The interpreter maintains the boundaries of
the professional role, refraining from personal
involvement.
The interpreter continuously strives to
develop awareness of his / her own and other
(including biomedical) cultures encountered
in the performance of their professional
duties.
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NCIHC Code of Ethics, continued
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The interpreter treats all parties with respect.
When the patient’s health, well-being, or
dignity is at risk, the interpreter may be
justified in acting as an advocate.
The interpreter strives to continually further
his / her knowledge and skills.
The interpreter must at all times act in a
professional and ethical manner.
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National Code of Ethics for Interpreters
in Health Care
“The role of interpreter is a
‘tightrope’ balancing act: A code of
ethics is a good guide for the ‘bar’
carried on such a walk on the
tightrope. It offers balance, some
security and especially is a
comfortable way to face the unknown
risks faced on the interpreter’s path.”
Anonymous Respondent to Code of Ethics
Survey quoted in a June 2005 ppt presentation on the Internet
by Shiva Bidar-Sielaff, MA; Manager of Interpreter Services &
Minority Community Relations-University of Wisconsin Hospital &
Clinics Board Member, NCIHC.
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For more about Ethics, take
Ethics for Healthcare Interpreters (about 1
hour) at http://learn.hcin.org/
A brief introduction to the ethics of healthcare
interpreting, based on prevailing standards set
by professional associations in the field. This
course is offered thanks to Suzanne Couture,
CHI™, a student of Instructional Technology
Design, who approached us with a proposal.
2014
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What is a “Standards of Practice”
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Set of behavioral and professional
expectations
Definition of conduct and practice
Reflection of existing best practices and
prevailing consensus in the field
The “hows” where ethics are the “shoulds” or
the abstract principles
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NCIHC Standards of Practice

The National Council on Interpreting in Health
Care (NCIHC) developed 32 standards to
provide guidance on the qualifications and
proper role of the interpreter and define what
constitutes good practice. They are designed
to promote better communication between
patients and health professionals who do not
share a language and improve the quality of
care for these patients.
Text from: http://www.commonwealthfund.org/
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NCIHC Standards provide guidelines
on the following nine ethics:
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Accuracy: To enable other parties to know precisely what each
speaker has said.
Confidentiality: To honor the private and personal nature of the
health care interaction and maintain trust among all parties.
Impartiality: To eliminate the effect of interpreter bias or preference.
Respect: To acknowledge the inherent dignity of all parties in the
interpreted encounter.
Cultural Awareness: To facilitate communication across cultural
differences.
Role Boundaries: To clarify the scope and limits of the interpreting
role, in order to avoid conflicts of interest.
Professionalism: To uphold the public's trust in the interpreting
profession.
Professional Development: To attain the highest possible level of
competence and service.
Advocacy: To prevent harm to parties whom the interpreter serves.
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Medical Interpreting Standards of
Practice, IMIA
Identifies 3 duties:
A. Interpretation (18 standards)
B. Cultural Interface (2 standards)
C. Ethical Behavior (7 standards)
And groups standards of practice around these
themes. Use as:

1. Guideposts in the development of educational and training
programs.
2. Evaluation tool.
3. Preparation of health care providers to work with interpreters.
4. Foundation for a certification examination.
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CHIA’s publication spelled out
protocols in this way:
Protocol 1. Pre-Encounter, Pre-Session, or PreInterview
Protocol 2. During the Encounter, Session, or
Interview
Protocol 3. Post-Encounter, Post-Session, or
Post-Interview (make sure session has ended, debrief if nec.)
(Protocol: a set of steps or actions)
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Positioning – in CHIA Standards, under
protocols, during the session, interpreters “Position themselves to
maximize and encourage direct communication between patient
and provider.”
•Can support the three-way
partnership and balance the unequal
perception of power in the healthcare setting.
•Supports the patient and provider
relationship by directing the provider and
patient to look at each other and to speak to
each other when they speak.
Source: Katharine Allen
2014
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Positioning choices: triangle
Triangle Positioning:
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Frequently used position in
healthcare/social service
settings.
Allows provider & patient to
look at interpreter
when they speak.
Interpreter becomes the
center of the session.
Provider & patient misses
important non-verbal queues.
Provider patient fail to
develop primary relationship.
Provider
For spoken
languages via
video, this is best
arrangement.
Interpreter
Source: Katharine Allen
Patient
2014
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Positioning choices: Interpreter next to
provider
 Provider can look and
speak directly to the
Provider
Interpreter
patient.
 Patient may look at
provider or
interpreter when
speaking.
For ASL via
video, this is
 Patient may feel
best
intimidated with
arrangement.
the feeling of two
against one.
Source: Katharine Allen
2014
Patient
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Positioning choices:
Interpreter next to patient
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Provider can look and speak
directly to patient.
Patient is more likely to look
at the provider when
speaking.
Patient may feel supported
during the visit.
Patient more likely to
develop primary
relationship with provider.
Source: Katharine Allen
2014
Patient
(This idea came from
whisper interpreting
model.)
Provider
Interpreter
NOTE: Interpreter will need to use skills to keep
provider and patient looking and speaking to
each other. Hand gestures, eye contact and
verbal reminders can be used to encourage
direct communication between the provider and
patient.
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Determine the Interpreting Mode,
Modes, or Ways, of Interpreting—the actual skills
are tested in Part 2 of both exams—but for the
written exam review what mode is best for what
setting.
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Consecutive
Simultaneous*
Sight translation*
(*two modes not included on NBCMI test.)
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About the section on sight
translation and translation (CCHI)
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In the oral part of CCHI’s test, there is a section
on sight translation and translation. This
combined section counts for 10-15% of the total
score.
For the sight translation, you will record yourself
and your rendition of a short text.
For the section on translation, the test questions
are multiple choice. Your task is to choose the
best translation of a short text. You are not
required to actually translate.
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Don’t worry.
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There is a high level of consensus about
what interpreters should know and do.
You do not need to memorize lists of ethics
or standards
or know about
differences
btwn the
publications.
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Improve your medical terminology
Anatomy vs. Physiology from dictionary.com
Anatomy
1. the science dealing with the
structure
of animals and plants.
2. the structure of an animal or plant, or of any of its
parts.
3. dissection of all or part of an animal or plant in order
to study its structure.
4. a plant or animal that has been or will be dissected,
or a model of such a dissected organism.
5. a skeleton.
6. Informal. the human body.
7. an analysis or minute examination.
Physiology
1. the branch of biology dealing with the
functions
and activities of living
organisms and their parts, including all physical and
chemical processes.
2. the organic processes or functions in an organism or
in any of its parts.
NBCMI test: medical
terminology 38%
CCHI: 22 – 25%
2014
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Look up the function of
organs. (Eng. To Eng.) Example:
The gallbladder is a pear-shaped, hollow structure
located under the liver and on the right side of the
abdomen. Its primary function is to store and concentrate
bile, a yellow-brown digestive liquid produced by the
liver. The gallbladder is part of the biliary tract. The
gallbladder serves as a reservoir for bile that is not
immediately used for digestion... The bile helps the
digestive process by emulsifying fats and neutralizing
acids in partially-digested food. An excess of cholesterol,
bilirubin or bile salts can cause gallstones to form.
NBCMI test
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More? Understanding Medical Words: A
Tutorial from the National Library of
Medicine
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Tutorial teaches you about medical words. You'll
learn about how to put together parts of medical
words. You'll also find quizzes to see what
you've learned. You need Flash Player to view
the programs. (70 or so slides)
http://www.nlm.nih.gov/medlineplus/medicalword
s.html
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More? Coursera course

Clinical Terminology for International and U.S.
Students offered by the University of
Pittsburgh.
6 weeks starting February 9, 2015
2-4 hours of work / week
English, English subtitles
If you sign up now you will receive emails from them reminding you
about the course. The course is free but a person who wants a
certificate verifying complete participation needs to pay $49. The course
offers a lot of instruction and content for that price.
To learn more about it, copy this string into your browser.
https://www.coursera.org/course/clinicalterminology
2014
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Legislation and Regulations
(3% of NBCMI / and a similar fraction of
Interact with other Healthcare
Professionals - CCHI)
We won’t spend much time, so this is the quick
list:
1. Civil Rights Act of 1964, Title VI
2. OCR and LEP Guidance
3. CLAS
4. HIPAA
5. Joint Commission
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What are Civil Rights?
Answer: Civil rights are personal rights
guaranteed and protected by the U.S. Constitution
and federal laws enacted
by Congress, such as the Civil Rights Act
of 1964 and the Americans with Disabilities
Act of 1990. Civil rights include, for example,
freedom of speech, the right to vote, due
process of law, equal protection of the laws,
and protection from unlawful discrimination.
http://www.hhs.gov/faq/policies/civilrights/86.html
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Title VI of the Civil Rights Act of
1964 protects persons from discrimination based
on their race, color, or national origin.
The 1964 law does not address language specifically. However, the Office for
Civil Rights explains much later that the language a person speaks is related to
his or her “national origin.” In its “Policy Guidance on the Prohibition Against
National Origin Discrimination As it Affects Persons with Limited English
Proficiency” the OCR explains that national origin discrimination includes
practices that result in denying a service or other benefit provided as a part of
health or social services.
For more information, visit
http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/
(Title II of this Act outlawed discrimination based on race, color, religion or national origin in hotels, motels, restaurants,
theaters, and all other public accommodations engaged in interstate commerce; exempted private clubs without defining
the term "private". Title VII prohibits discrimination by covered employers on the basis of race, color, religion, sex or
national origin.)
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Culturally and Linguistically
Appropriate Standards (CLAS)
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The 14 standards are organized by themes:
Culturally Competent Care (Standards 1-3),
Language Access Services (Standards 4-7), and
Organizational Supports for Cultural Competence
(Standards 8-14).
Standards 4 through 7 are based on Title VI and
LEP Guidance. The other guidelines are
recommended by Office of Minority Health (OMH
of US Dept of Health and Human Services) for
adoption as mandates. You can find the full list
here:
http://www.imiaweb.org/resources/clas.asp
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Standard 4 - Health care organizations must
offer and provide language assistance services,
including bilingual staff and interpreter services,
at no cost to each patient/consumer with limited
English proficiency at all points of contact, in a
timely manner during all hours of operation.
Standard 5 - Health care organizations must
provide to patients/consumers in their preferred
language both verbal offers and written notices
informing them of their right to receive language
assistance services.
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Standard 6 - Health care organizations must
assure the competence of language assistance
provided to limited English proficient
patients/consumers by interpreters and bilingual
staff. Family and friends should not be used to
provide interpretation services (except on
request by the patient/consumer).
Standard 7 - Health care organizations must
make available easily understood patient-related
materials and post signage in the languages of
the commonly encountered groups and/or
groups represented in the service area.
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HIPAA
HIPAA The Health Insurance
Portability and Accountability Act of
1996 was enacted by the United
States Congress and signed by
President Bill Clinton in 1996.
Title I of HIPAA protects health
insurance coverage for workers and
their families when they change or
lose their jobs. Title II of HIPAA
defines policies, procedures and
guidelines for maintaining the privacy
and security of individually
identifiable health information as
well as outlining numerous offenses
relating to health care and sets civil
and criminal penalties for violations.
2014
Common HIPAA
violations, according to
HHS (www.hhs.gov),
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Misuse and disclosures of PHI
No protection in place of health
information
Patient unable to access their
health information
Using or disclosing more than
the minimum necessary
protected health information
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Want to know more re
HIPAA?
UCLA Medical Center has an online training
on HIPAA that is accessible to the public
“HIPAA Privacy and Information Security
Training for New Workforce Members.”
http://hshr.mednet.ucla.edu/s/trainings/policies
procedures/publish/ocr.htm
 Their quiz has 11 questions. Good practice.
It's here:
https://hshr.mednet.ucla.edu/s/trainings/policies
procedures/publish3/quiz.htm

2014
Beverly Treumann for Health Care
Interpreter Network
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Joint Commission

What is it?
The Joint Commission is an independent, notfor-profit organization accredits and certifies
more than 20,500 health care organizations
and programs in the United States.
It is not a federal agency, but its attention to
language access is helping to improve
compliance with federal law.
2014
Beverly Treumann for Health Care
Interpreter Network
53
New standards
“The new patient centered communication
standards expect that individuals who provide
language services for the hospital meet the
qualifications defined by the organization. …The
hospital has the flexibility to define the
qualifications for their interpreters and
translators, and they would be expected to
demonstrate that their interpreters/translators
meet the hospital’s qualifications.”
2011 Language Line Services White Paper The New Joint Commission Standards for
Patient-Centered Communication; Hospitals Remain Unprepared As The Joint
Commission Standards Go Into Effect
2014
Beverly Treumann for Health Care
Interpreter Network
54
My opinion:
Both tests are good. Managers should hire people
who have earned either credential.
I prefer CCHI’s test because I prefer the content
covered in Parts 1 and 2. In Part 1, there’s more about
ethics, standards and how to manage a session. We are
still in an early stage of standardizing the profession and
we need to know that interpreters know and agree about
what to do in common scenarios. I also like it that CCHI
awards a credential to anyone who passes Part 1. It’s
called CoreCHITM and it can be earned by interpreters for
whom no oral test has been created.
7/18/2015
Beverly Treumann for
Health Care Interpreter Network
55
My opinion:
I thought some of the test questions on the NBCMI
could have been written more clearly. The questions about
organ function, prescribed medicines, and medical devices,
are not part of what I would ask a job candidate as a way
to determine that he or she is ready to work as an
interpreter.
7/18/2015
Beverly Treumann for
Health Care Interpreter Network
56
The market for interpreter
certification

"As we stated before, it is in Language Line’s
business interests to make medical certification
a reality as quickly as possible — not because it
stands to make any significant money from
actually selling its own test — but in order to
prevent further price compression in its core
telephone interpreting market." Nataly Kelly
13 October 2009 Common Sense Advisory
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Other considerations when you
make your choice:
• Available test
locations
• Languages tested
• Skills tested (In the
oral exam,
simultaneous and
sight translation
are tested by
CCHI.)
• Price: CMI lasts 5
years, CHI 4 years
2014
Beverly Treumann for Health Care
Interpreter Network
58
Please complete a quiz and
evaluation here:

2014
https://www.surveymonkey.com/s/8LGLZQQ
Beverly Treumann for Health Care
Interpreter Network
59