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Cover Note: The SHARE Approach is a 1-day training program developed by the Agency for Healthcare Research and Quality (AHRQ) to help health care professionals work with patients to make the best possible health care decisions. It supports shared decisionmaking through the use of patient-centered outcomes research (PCOR).

Communication barriers get in the way of good health care

This guide offers tips for overcoming communication challenges so you and your patients (and the families and friends who accompany them) can engage in effective shared decisionmaking. This guide also focuses on ways to efficiently work with qualified medical interpreters.

Language, hearing, and visual barriers are common in the United States

Consider the statistics:

• Approximately 9 out of 100 people have limited English proficiency.
• More than 3 out of 100 people have a hearing disability. That means they are deaf or have severe trouble hearing.
• More than 2 out of 100 people have a visual disability. That means they are blind, or have severe trouble seeing, even with glasses.

Set the stage for good communication

Shared decisionmaking helps patients take charge of their care. In order to give fully informed consent, patients need information they can understand. Their companions (family members or friends who accompany them) do, too.

Check off the strategies you will try.

___ Assess and record your patients' communication needs. Choose decision aids that match the needs of your patients.
___ Find or train qualified medical interpreters.
___ Tell patients (and companions)—verbally and in writing—that you provide interpreters and decision aids that enhance communication.
___ Train staff to better serve patients who have communication barriers.
 

Choose decision aids that enhance communication

There are many decision aids that can transcend barriers to communication. Here are just a few.

Language barriers

• Materials that are culturally appropriate, translated, or written in plain language.
• Visuals like pictures and graphs.

Hearing barriers

• Print materials.
• Text telephones (TTYs).
• Videos with captions.
• Written instructions.

Visual barriers

• Audio recordings.
• Large-print materials and screen magnifiers.
• Screen reader software (a software application that is a form of assistive technology, which can re-present information in text-to-speech, sound icons, or a Braille output device).

Qualified medical interpreters can help with language or hearing barriers

Qualified medical interpreters can be certified freelance interpreters; employees from language agencies; trained bilingual clinicians and staff; or community-based medical interpreters from local colleges, faith-based organizations, social services programs, migrant health clinics, and more.

The use of unqualified interpreters—such as a family member, minor child, friend, or unqualified staff member—is not advisable. That choice is more likely to result in misunderstandings and medical errors.

Language barriers

A qualified medical interpreter who helps people with limited English proficiency is trained in:

• Ethical standards.
• Cultural issues.
• Health care words and concepts.
• How to interpret between languages.
• How to translate instructions.
• Relevant languages for your patients.
• Correct positioning in the room.

Hearing barriers

There are several types of qualified medical interpreters that help people who are deaf or hard of hearing.

• Sign language interpreter. This person uses American Sign Language or Signed English.
• Oral interpreter. This person articulates silently and clearly, and uses gestures.
• Cued-speech interpreter. This person does everything an oral interpreter does, but also uses a hand code to stand for each speech sound.

Checklist for working with qualified medical interpreters onsite

Before the visit

___ Gather any needed decision aids. Make sure they match the communication needs of your patient (and their companions).
___ Tell the interpreter what the visit will be about. Make sure the interpreter understands the information, especially if the patient's life may be at risk.

During the visit, make sure

___ Everyone in the room can see each other.
___ Your patient knows the interpreter's name and what the interpreter will do.
___ Your patient knows that the interpreter is a confidential source who will not share any of the information.
___ Your patient is making the health care decisions. Some patients defer to their interpreter to make choices for them.
___ Your patient understands the main points. Use teach-back to make sure you presented information in a way your patient understands. Have your patient explain to you, in his or her own words, what you said. Ask the interpreter to tell you exactly what your patient said so you can check for comprehension.

Working with offsite qualified medical interpreters

When working with offsite interpreters, make sure you and your staff know how to use any needed equipment, such as dual handsets or speaker phones in the exam rooms.

Over-the-phone interpreters

Trained telephonic interpreters provide offsite multilingual interpretation to the patient and health care provider by telephone. This service is also called a language line.

Videoconferencing

The interpreter can see, hear, and assess the body language of the patient and the health care provider via a video remote interpreting service.

Avoid working with untrained (or unqualified) medical interpreters

Using unqualified medical interpreters should be avoided to protect patients and providers. Still, at times, your patient may want their bilingual family member to interpret for them—and, of course, you want to honor their request.

Letting your patients use an interpreter of their choice does not, however, mean a qualified medical interpreter cannot be present to make sure no mistakes are made. Using untrained staff to interpret has been shown to lead to clinically significant medical errors.

There are challenges with using unqualified interpreters

• They may be unfamiliar with technical or scientific language.
• They may inadvertently commit interpretive errors.
• They may editorialize your patient's responses.
• When a family member interprets, the person may impose their view of your patient's health and this may also pose a problem with patient privacy.
• When a minor child interprets, the child is in a very vulnerable position and the practice is at risk for liability if something goes wrong. Also, your patient may be less likely to discuss more personal health topics when a minor child interprets.

If you must work with an untrained interpreter, make sure information is being exchanged accurately.

Try these tips:

• Never use minor children to interpret.
• Remind the interpreter to interpret everything accurately and completely.
• Ask the interpreter to avoid paraphrasing or answering for your patient.
• Interact frequently with your patient and use teach-back.

Funding qualified medical interpreters

Here are some ways to pay for qualified medical interpreters:

• Find out if your State's Medicaid or State Child Health Insurance Plan reimburses for interpreters or contracts with interpreter organizations.
• Develop collaborative contracts with other practices and hospitals in your region for onsite interpreters or an offsite telephone interpreter service.
• Arrange for your bilingual staff to get trained and become qualified medical interpreters.

Learn more about resources for health care providers

For information about working with qualified medical interpreters and cultural competency, visit:

• A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations
  
• Health Literacy Universal Precautions Toolkit, Tool 9, pages 41-45, How to Address Language Differences, AHRQ Pub. No. 10-0046-EF
  http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthliteracytoolkit.pdf (339 KB)

Learn more about resources for patients

For culturally appropriate interactive decision aids from the Agency for Healthcare Research and Quality, visit:

For consumer research summaries that compare treatment options for a variety of health conditions (most in both English and Spanish), visit:

A limited number of copies are available at no cost through the Â鶹´«Ã½ Clearinghouse. All AHRQ resources are freely available online.

This tool is to be used in conjunction with the Agency for Healthcare Research and Quality's SHARE Approach workshop. To learn more about the workshop, visit www.ahrq.gov/shareddecisionmaking.

Bibliography

A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations. Prepared by American Institutes for Research, under Contract No. 282–98–0029, Task Order No. 48 Office of Minority Health. 2005.

Disability Status Report United States. Employment and Disability Institute at the Cornell University ILR School. 2011.

Flores G. Language barriers to health care in the United States. N Engl J Med 2006 Jul 20;355(3):229-31. PMID: 16855260.

Betancourt J., Renfrew M., Green A., et al. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals. Prepared by The Disparities Solutions Center, Mongan Institute for Health Policy, under Contract No. HHSA290200600011I. AHRQ Publication No. 12-0041. Rockville, MD: Agency for Healthcare Research and Quality; November 2012.

Schapira L., Vargas E., Hidalgo R., et al. Lost in translation: Integrating medical interpreters into the multidisciplinary team. The Oncologist 2008 May;13(5):586-92. PMID: 1851574.

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