Procedure for the Determination of LEP Status:
- The first access point in which a patient acquires medical services at Chinese Hospital (i.e., Treatment Center, nursing unit, etc.) shall incorporate the determination of language needs into first intake procedures.
- The patient or surrogate decision-maker shall be asked the following questions during the course of the interactive process:
- Do you speak a language other than English at home? If the answer to this question is yes, the language will be noted and documented in patient records.
- In what language do you prefer to receive your medical services?
- In what language do you prefer to receive written materials?
Procedure for the Inclusion of Patient Primary Language and Documentation of the Provision of Interpreter Services in Patient Medical Records:
- Each medical record shall show the primary language spoken by the patient/surrogate decision-maker.
- The patient need for interpreter services shall be included in the nursing assessment for inpatient admissions.
- Documentation of the provision of interpreter service, if needed, will be in the patient medical record during the provision of medical and nursing procedures requiring interpreting.
Procedure to Inform Patients of their Right to Have Interpreter Services
- During the interview as the patient first acquires medical services at Chinese Hospital, LEP patients shall be informed verbally or in the written form of the patient’s primary language (when it is clear the patient will not be able to understand English or the translated frequently utilized languages at Chinese Hospital) of their right to have a healthcare interpreter in their language, free of charge, within a reasonable time.
- Chinese Hospital shall develop, and post in conspicuous locations, notices in English and Chinese (frequently utilized language at Chinese Hospital) that advise patients and their families of the availability of interpreters, the procedure for obtaining an interpreter and the telephone numbers where complaints may be filed concerning interpreter service problems, including, but not limited to, a T.D.D. number for the hearing impaired.
- The notices shall be posted, at a minimum, in the Treatment Center, the admitting area, the entrance, and in outpatient areas.
- Notices shall inform patients that interpreter services are available upon request, shall instruct patients to direct complaints regarding interpreter services to the state department, and shall provide the local address and telephone number of the state department, including, but not limited to, a T.D.D. number for the hearing impaired.
Procedure for the Identification and Implementation of Required Bilingual Position
- Specific recruitment criteria for Chinese Hospital shall be designed for units where patient populations reach over 25% from any language other than English, the departmental manager will submit to the Human Resources department proposals to designate Required-Bilingual Positions in their unit. Where there are multiple positions (such as hospital operators, financial counselors, social workers, etc.), an appropriate proportion of positions shall be required to be bilingual designated.
Procedure for Language Accessible Hospital Signage
- Hospital signage shall be designed to ensure access to LEP populations most frequently using Chinese Hospital facilities. When the patient populations of Chinese Hospital reach a proportion of 25% from a primary language group other than English, all hospital signage, including state and federal statutes, regulations and licensing requirements, shall be designed in both English and that language.
- Additional languages for the translation and way-finding signage shall be added at the discretion of hospital management. These requirements for translation of hospital signage shall be implemented during the creation of any new signage.
Procedure for Adjustment of Hospital Equipment Requirements to Assure Language Access
- Clinical areas shall be equipped with devices necessary for the routine delivery of remote interpreter services through telephone. Service areas requiring devices for the delivery of remote interpreter services include (but are not limited to) the following:
- All stations of patient registration, financial counseling, and admission;
- All nursing stations.
- Devices to allow effective access to remote interpreter services may include the following:
- Dual handset and/or headset telephones
- Telephones equipped with three-way call capability for telephone-based services
- Current standards shall be applied to all new outfitting activities involving hospital telecommunication services, including renovations and new facilities construction.
- New equipment purchases and redesign of existing facilities to meet these standards shall be incorporated into the ongoing hospital capital acquisition processes.
- Equipment purchases in medical settings that most greatly affect quality of care, patient safety, and improved patient outcomes will be designated for immediate remediation.