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Interpreter Services and/or Language Assistance (3.3.4)

Interpreter Services and/or Language Assistance (3.3.4) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Communication


Policy Title: Interpreter Services and/or Language Assistance
Policy Number: 3.3.4
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 18, 2015


To provide for the communication needs of Limited English Proficient (LEP) and Deaf or Hard-of-Hearing
patients and families; to provide for the use of qualif ied medical interpreters and bilingual staff ; to provide for
the to provide special communication devices to the Deaf and Hard-of-Hearing patients; and to provide
interpreter and translation services to patients and families in accordance w ith applicable State and Federal
Law s.


"Qualified Interpreter" or "interpreter" - A medical interpreter is a specially trained professional w ho has
been assessed for professional skills, demonstrates a high level of proficiency in at least tw o languages and
has the appropriate training and experience to interpret in the medical setting w ith skill and accuracy w hile
adhering to the National Code of Ethics and Standards Practice published by the National Council on
Interpreting in Health Care. In order to be deemed qualif ied, UW health interpreters are required to be
nationally certif ied by the Certif ication Commission for Healthcare Interpreters (spoken languages) or the
Registry of Interpreters for the Deaf (American Sign Language.) Only those interpreters deemed to be
qualif ied by the Interpreter Services department shall be authorized to interpret at UW Health. Interpreters
provided by Pacif ic Interpreters and Language Line Services are deemed qualif ied interpreters.

“Bilingual staff” are UW Health staff and providers w ho have demonstrated proficiency in a language other
than English.

"Limited English proficient (LEP) patients” are patients w hose primary language is not English and w ho
cannot speak, read, w rite or understand the English language at a level that permits them to interact
effectively w ith health care providers.

"Pacific Interpreters" and "Language Line Services®" are services that provide 24-hour remote
interpreting services via telephone (over-the-phone interpreting or OPI) or video. Pacif ic Interpreters is our
primary over-the-phone interpreter provider, and Language Line Services serves as a back-up (see IV.B.iii.
for more details).

"Patient's Authorized Representative" is the person authorized by law or hospital policy to act on behalf
of a patient w ho lacks decision-making capacity. (Reference UWHC policy #4.17, Informed Consent)

"Vital Documents" are paper or electronic documents that contain information that is critical for accessing
services. Examples of such documents are informed consent forms, letters or notices that require a
response from a patient, documents that inform patients of free language assistance, and notices of
eligibility criteria for, rights in, denial or loss of, or decreases in benefits or services.


It is the policy of UW Health to provide equal access to and equal participation in health care activities for
Limited English Proficient and Deaf or Hard-of-Hearing individuals. UW Health provides communication
assistance at no cost to the patient during the course of care as w ell as during health education programs
and any other contact w ith patients and families. It is the policy of UW Health to provide language assistance
through qualif ied medical interpreters.


A. Notif ication of Rights to LEP Patients/Families.
UW Health informs LEP patients/families of the follow ing rights:
i. A qualif ied interpreter at no cost to them.
ii. Not to rely on their friends or family members as interpreters.

Policy Title: Interpreter Services and/or Language Assistance
Policy Number: 3.3.4

iii. To f ile a grievance about any aspect of their care at UW Health, including language assistance.
iv. UW Health provides w ritten patient rights and responsibilities in Spanish. Additionally, a notice of
rights is available in the 20 most frequent languages spoken by our patients.
B. Identif ication of Patients Who Require Language Assistance (LEP patients.)
When registering a new patient in Health Link, staff shall record w hether a patient needs interpreter services
and the language s/he speaks by entering the language spoken in the Interpreter Required (Interpreter Req)
f ield in demographics. IMPORTA NT: If a patient is Limited English Proficient or needs a Sign Language
interpreter, staff shall ALWAYS complete the "Interpreter Required" f ield regardless of w hether the patient
has someone w ith them to interpret. This f ield triggers the follow ing scheduling processes:
i. Outpatient appointments: Patients w ho have been properly identif ied as needing an interpreter in
Health Link w ill have an interpreter available for the appointment. The Interpreter Services
Department receives reports as soon as an appointment is scheduled. Upon receipt of the report,
the Department w ill begin to w ork on scheduling an interpreter. An interpreter w ill be assigned
either "in person" (face-to-face interpreter w ill be present) or by "phone" or “video” (Pacif ic
Interpreters is our primary remote interpreting provider). The information on w hat type of interpreter
has been assigned w ill appear on the appointment desk and can also be added to clinic Daily
Appointment Reports (DARs.). In some cases, an in-person interpreter w ill not be needed for every
appointment. Interpreter Services staff w ill discuss this on a case-by-case basis w ith the clinic staff
and patient. Examples include ongoing appointments such as dialysis, physical therapy or home
health aide visits.
ii. Inpatient hospitalizations: Clinical staff w ill need to request an interpreter through the Heath Link
Computerized Provider Order Entry (CPOE). Once an order is entered into CPOE, the Interpreter
Services Department w ill begin to w ork on scheduling an interpreter. An interpreter should be
requested at least once a day for rounds and nursing assessments and as needed for other
discussions, tests and procedures. It is the responsibility of the ordering provider to also enter an
order into CPOE for an interpreter for the tests and procedures. For the list of situations for w hich
an interpreter should be used, see Section IV.D.
iii. When an in-person interpreter is not available our phone or video interpreter services provider,
Pacif ic Interpreters, w ill need to be used. Pacif ic Interpreters has interpreters for over 200
languages/dialects available on demand - 24 hours a day, 7 days a w eek, 365 days a year. For
details on how to access a phone or video interpreter, please visit U Connect>Departments &
Programs>Interpreter Services
iv. After hours, staff should contact:
a. The Spanish Interpreter On-Call: pager 2030.
b. The Sign Language Interpreter On-Call: pager 2031.
c. All other languages and language assistance needs: contact the Nursing Coordinator
(pager #7576), the Paging Operator and/or use Pacif ic Interpreters.
v. For Health Education Activities/Seminars, it is helpful if the organizers of the event contact the
Interpreter Services Department at least 10 w orking days before the event to request an interpreter
for any participant w ho has identif ied the need for one.
C. Communication Devices/Adaptive Equipment. The Interpreter Services Department w ill w ork w ith staf f to
identify specif ic communication devices needed for patients, i.e. telephone amplif ication devices,
speakerphones, and illuminated magnif iers. To discuss a patient specif ic need, call Interpreter Services at
D. Use of Interpreters.
i. Interpreters shall be used in any situation w here clear and effective communication is necessary.
Situations in w hich the presence of an interpreter for Deaf, Hard-of-Hearing or Limited English
Proficient patients is necessary to ensure thorough and accurate communication include, but are
not limited to:
a. Discussing a patient’s symptoms and medical condition, medications, and medical history
b. Explaining and describing medical conditions, tests, treatment options, medications, and
surgery or other procedures
c. Providing a diagnosis, prognosis, and recommendation for treatment
d. Obtaining informed consent for treatment
e. Communicating w ith a patient during treatment, testing procedures, and during physician’s
f. Providing instructions for medications, post-treatment activities, and follow -up treatments

Policy Title: Interpreter Services and/or Language Assistance
Policy Number: 3.3.4

g. Providing mental health services, including group or individual therapy, or counseling for
patients and family members
h. Providing information about blood or organ donations
i. Explaining living w ills and pow ers of attorney
j. Discussing complex billing or insurance matters
k. Making educational presentations, such as birthing and new parent classes, nutrition and
w eight management counseling, and CPR and first aid training
ii. In emergency situations, treatment w ill be provided in accordance w ith standard medical practice.
Emergency care w ill not be delayed pending the arrival of an interpreter. All reasonable efforts w ill
be made to promptly locate an interpreter -- this includes the use of phone or video interpreter
services (see IV.B.iii.).
iii. Interpreters w ill generally accompany patients to medical procedures, to the OR Holding Room, to
the Post-Anesthesia Care Unit and, if needed, to the OR.
iv. Minor children (under the age of 18) should NEVER be used as interpreters.
v. Family and friends should not be asked or required to interpret for LEP or Deaf/Hard of Hearing
patients. The use of family and friends may result in omissions, substitutions and semantic errors
that distort care. It may breach confidentiality, may upset familial relationships and hierarchies that
are deeply rooted in culture, and may be particularly problematic w hen dealing w ith sensitive
issues, such as, reproductive health, sexually transmitted diseases and mental health. Therefore, if
the patient feels strongly that a family member or friend should be used in lieu of a qualif ied
medical interpreter, after being advised that a qualif ied interpreter is available at no cost, the patient
w ill need to sign the Refusal of Interpreter Form (UWH# 301687-DT). Even w hen a refusal of
interpreter form is signed, UW Health reserves the right to have a qualif ied medical interpreter
present during any encounter.
vi. UW Health medical interpreters serve as interpreters for UW Health. UW Health medical
interpreters do not serve as interpreters for others, including, but not limited to, law enforcement
and governmental administrative personnel and non-UW Health attorneys.
E. Written Translations.
i. Any document in a language other than English given to patients and families by or on behalf of
UW Health should be approved by the Interpreter Services Department (except for IRB-approved
translations of research consent forms and translations of government documents provided by
government agencies).
ii. All translations of UW Health produced documents must be coordinated by the Interpreter Services
Department in order to ensure the accuracy of the translation. Vital documents and numerous
patient education materials have been translated into Spanish and, in some instances, other
languages. These translations are available through U-Connect.
iii. Requests for translations: staff should contact the Interpreter Services Depar tment. The Director of
Interpreter Services and the requesting department manager or provider w ill evaluate the need for
such translation based on a number of factors including number of patients served, critical nature of
the document, assessment of the patient’s communication needs, evaluation of other effective
alternatives (i.e. phone call, audio recording).
F. Approval of Interpreters.
i. The Interpreter Services Department is responsible for the evaluation of a prospective interpreter's
qualif ications. Individuals interested in interpreting, including bilingual UW Health staff, must f ile an
application w ith the Department of Interpreter Services and be deemed qualif ied by the Director of
Interpreter Services. A list of approved interpreters is maintained in the Interpreter Services
ii. If a patient or a patient's authorized representative insists upon a friend or family member
interpreting or refuses to have an interpreter, staff should contact the Interpreter Services
Department. The patient or patient's representative should be made aw are of his/her right to a
qualif ied interpreter at no charge. If, after understanding his/her rights, the patient or patient's
representative continues to refuse the presence of a qualif ied interpreter, s/he w ill be required to
sign a Refusal of Interpreter From releasing UW Health from liability for any adverse consequences
w hich may result from interpreting w hich is provided by an interpreter not approved by UW Health
(Refusal of Interpreter Form UWH# 301687-DT) Scan. Even if the patient or patient's
representative refuses to use a UW Health approved interpreter, UW Health staff can still request
the presence of such interpreter to ensure accurate communication.
iii. NOTE: UW Health staff may not require that a patient's friends or family members interpret for a

Policy Title: Interpreter Services and/or Language Assistance
Policy Number: 3.3.4

patient. Doing so is a violation of the August 8, 2003 US DHHS Office for Civil Rights Policy
G. Bilingual Staff
Interpreter Services is responsible for the language proficiency evaluation of providers w ho identify as
bilingual and w ould like to practice in the non-English language. Providers shall contact the Director of
Interpreter Services w ho w ill determine w hether they meet the proficiency level required to practice in the
non-English language based on the follow ing parameters:
o If provider has a college degree from the country w here the non-English language is spoken, the
provider shall be deemed qualif ied to provide care w ithout the presence of an interpreter for said
o All other providers shall take the Language assessment developed by Kaiser Permanente and
administered over the phone by ALTA Medical Language Testing. Interpreter Services w ill arrange
for a date and time for the assessment and provide the passw ord to the provider. The provider w ill
share test results w ith Interpreter Services. If the provider passes the assessment, s/he shall be
deemed qualif ied to provide care w ithout the presence of an interpreter for said language.
Bilingual staff are not considered qualif ied interpreters.
H. Staff Training and Resources.
i. The institution's 504 Coordinator (located in the Department of Interpreter Services) to the Deaf,
Hard-of-Hearing and limited English proficient patients shall assure that clinic staff, physicians and
other appropriate personnel are trained in the follow ing:
a. Communication needs of the Deaf, Hard-of-Hearing and patients w ith limited English
b. When and how to use interpreters.
c. How to use the phone or video interpreter services and other communication
devices/adaptive equipment
ii. All new employees w ill receive information about interpreter services and communication devices
during New Employee Orientation. Refresher training w ill be offered periodically.
I. Designation of LEP Coordinator. UW Health's Interpreter Services Director shall serve as the Limited
English Proficiency Coordinator (LEPC) to oversee the organization's compliance w ith regulatory
requirements and applicable law s. S/he w ill also be responsible for conducting an annual assessment and
plan as per the State of Wisconsin Civil Rights Compliance Plan in order to provide for the needs of LEP
populations likely to be served at UW Health.


Refusal of Interpreter Form UWH# 301687-DT


Author: Director, Interpreter Services and Community Partnerships
Senior Management Sponsor: VP, Quality and Patient Safety
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: November 16, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

Policy Title: Interpreter Services and/or Language Assistance
Policy Number: 3.3.4


-UWHC Administrative Policy #4.17, Informed Consent
-Title III of the Americans w ith Disabilities Act (ADA)
-Title VI of the Civil Rights Act of 1964
-Section 504 of the Rehabilitation Act of 1973
-Office for Civil Rights, HHS: Title VI of the Civil Rights Act of 1964; Guidance regarding the Prohibition
Against National Origin Discrimination As It Affecting Limited English Proficiency Persons (August 8, 2003)
-WI Law Sec. 101.22 (9) WI Statutes
-Madison Equal Opportunities Ordinance, sec. 3.23 (5) of Madison
- U.S. Department of Justice (DOJ), Civil Rights Division, Disability Rights Section. ADA Business Brief:
Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings . Washington, D.C.: DOJ
Civil Rights Division, 2003. Available at http://w ww.ada.gov/hospcombrscr.pdf.

Version: Revision
Next Revision Due: December 18, 2018
Formerly Know n as: Hospital Administrative policy #7.53; UWMF policy, Interpreter Services