I.        PURPOSE

To establish policy and procedures to ensure effective and efficient communication with limited English proficient (LEP) and hearing/speech impaired (HSI) persons to ensure their equal access to health, medical, behavioral health and social service programs, benefits and services.

II.       ACCOUNTABILITY

Under the direction of the Senior Vice President for Administration, the Associate Vice President for Affirmative Action and Equal Employment Opportunity (AA/EEO) shall ensure compliance with this policy in concert with the Deans and President/CEOs of the Healthcare Units who shall implement this policy.

III.      APPLICABILITY

All University patient care service providers and staff, including but not limited to, physicians, dentists, nurses, technicians, and behavioral health counselors.

IV.      DEFINITIONS

A.        HSI – Hearing/Speech Impaired - An individual who has had a loss of hearing, e.g. is deaf or hard of hearing and/or who is unable to speak or speak clearly enough to be understood.

B.        LEP - Limited English Proficiency - An individual of a national origin minority group with limited English proficiency. Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English may be limited English proficient, or "LEP," and may be eligible to receive language assistance with respect to a particular type of service, benefit, or encounter.

C.       TDD - Telecommunication Device for the Deaf – A device which allows conversation to take place over the telephone by sending typed messages through phone lines to the TDD screen.

D.       TTY - Teletypewriter - a precursor to the TDD.

V.       POLICY

No person shall be denied equal access to services based on his/her ability to communicate in the English language or due to hearing/speech impairment. It is the obligation of the University and all of its component schools/units to ensure that effective and efficient communication assistance and language services shall be provided to limited English proficient and hearing/speech impaired persons so that they have a complete understanding of information regarding medical condition, treatment and payment requirements.

A.       Patients/clients shall not be required to utilize family members, especially children, friends, or others awaiting services in the waiting areas as interpreters for the following reasons:

1.       Family or friends' emotional involvement with the patient/client can jeopardize interpretation of critical medical information.

2.       Such persons may not be versed in the medical terminology required for communication between patient/client and health professionals.

3.       Such use may compromise confidentiality.

B.      At the request of the patient/client, his/her own interpreter may be used after being advised that a free service is available and the use of this service would not compromise effectiveness of services or violate confidentiality. This request shall be noted in the patient/client's medical record.

Any available interpreter may be used in the case of an emergency; however, the use of a trained medical interpreter is preferred when and if available.

C.       Every patient care service delivery facility shall develop an internal procedure pursuant to this policy and communicate this policy and facility-specific procedures to all staff members who are in direct contact with patients/clients, including nurses, physicians, medical health technicians, receptionists, billing clerks, etc.

• Each such unit shall translate intake forms and patient assessments into patient languages. Such translations shall be deemed necessary when more than 10% of the identified LEP population is serviced.
• When possible, service delivery facilities may offer and encourage training for qualified bilingual employees desirous of volunteering their services as medical interpreters.

D.      The service delivery facility shall also develop a notification and outreach plan for LEP and HIS individuals. The following may be included in this plan:

• Posting signs in intake areas and other entry points in appropriate languages so that LEP persons may access language services. Signs in intake offices may state that free language assistance is available. The signs should be translated into the most common languages encountered and should explain how to access language assistance.
• Outreach documents may include statements that language services are available at the facility. Announcements of such services may appear in brochures, booklets, and recruitment information.
• Collaborating with community-based organizations and other stakeholders to inform LEP individuals of the facility’s services, including the availability of language assistance. 
•  Using a telephone voice mail menu in frequently-encountered languages. 
•  Notices in local newspapers in languages other than English.
• Providing notices of the language assistance services available to non-English language radio and television stations and how to access same.
•  Presentations and/or notices at schools and religious organizations.

E.       The mechanisms that will be utilized to provide communication assistanceinclude qualified staff interpreters, trained medical interpreters, appropriate telephone interpreter services, video-assisted technology, sign language interpreters, other qualified community/contract interpreter services, bilingual flash cards, translated forms, computer-based technology programs and patient educational materials. The service-providing unit shall pay all costs involved

VI.      PROCEDURES

A.      Upon reception or registration, staff should determine whether a patient/client is limited English proficient (LEP) or hearing/speech impaired (HSI) and as such may require special communication assistance. The following are methods to identify LEP individuals:

•  Language identification cards, such as, I speak Spanish in English and Spanish available at http://www.  Usdoj.gov/crt/cor/pubs/ISpeakCards2004.pdf;
•  review records of previously registered patients to identify language spoken by such patients; and
•  posting notices in commonly-encountered languages which informs LEP persons of the availability of language assistance and  encourages them to self-identify.

B.       If it is determined that communication assistance is necessary, the staff member shall inquire in what language the patient/client best communicates, or prefers. For patients/clients utilizing sign language, it is important to ascertain the type of sign language with which the patients/clients are familiar. This information shall be noted in his/her record. Patients/clients shall be made aware at each service entry point that they may request any of the communication services listed in Sections V.D. and VI.C.3.

C.      If the patient/client requests communication services:

1.        The staff member shall check the volunteer interpreter’s roster to identify an appropriate interpreter, preferably a trained medical interpreter. If no volunteer interpreter for the necessary language is available, another appropriate communication mechanism, described in V.D. shall be used.

2.        This information shall be noted in the patient/client record.

3.        For hearing/speech impaired patient/clients, either a text telephone (TTY or TDD) relay can be used at 1-800-852-7899 or 1-800-852-7897 or sign language interpreters can be obtained. This will require advance notice unless there is a staff member available who can interpret. Referral services can be obtained through the NJ Division of Deaf and Hard of Hearing (DDHH) at (609) 984-7283 to schedule an interpreter to be present for a patient/client's examination and/or treatment.

By Direction of the President:

__________________________________
Senior Vice President for Administration

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