Patients have the right to receive information in a manner that he or she understands. This policy outlines tools to assure access and continuity of care related to health care information and services for patients with communication barriers.

POLICY

In accordance with California's Health and Safety Code, Section 1259, a determination of any communication barrier will be made upon registration or upon initial nursing assessment of the patient.

A patient has the right to determine who will provide interpreter services to him/her. A patient may specifically request that an accompanying adult (family member/friend) interpret or facilitate communication. The accompanying adult must agree to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances. This determination must be made through either the telephone interpreting service or another non-hospital employed certified interpreter. The patient's choice will be documented in the patient's medical record. Reliance on an accompanying adult may be used in an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no qualified interpreter available. It is prohibited to rely on a minor child to interpret or facilitate communication, except in an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no qualified interpreter available.

Licensed professional healthcare practitioners and master level (MSWs) medical social workers who are bilingual may provide interpretation for non-healthcare related information as needed to patients if the patient agrees.

For all invasive procedures, issues involving domestic violence, sexually transmitted infections (STI), illicit drug use, or other situations involving sensitive personal information or informed consent, a formal interpreter service will be utilized. Formal interpreter services are the CyraCom Phone, and The Language People.

When a patient care conference is needed, an on-site interpreter through The Language People will be obtained through Social Services or the Administrative Coordinator to provide services for the patient and the family.

Signs will be placed in conspicuous locations such as the emergency department, registration areas, the hospital main entrance, and outpatient departments advising patients and their families of the availability of interpreting services.

Standardized written materials including Patient Rights and the Notice of Privacy Practice that are available to patients upon admission and upon discharge will be reviewed on a regular basis to determine which should be translated in languages other than English. Currently our geographic area meets the 5% requirement, Section 1259 of the Health and Safety Code, to have written materials translated in Spanish only.

TYPES OF BARRIERS

  • Language
  • Hearing/speaking
  • Visual

PROCEDURE

Screening:
All patients will have communication barrier(s) identified at the time of service by Patient Access or by Nursing Services. Communication barriers will be assessed upon admission and reassessed throughout the patient's stay and results will be documented in the electronic medical record.

Language Resources:
NorthBay Healthcare contracts with CyraCom for 24 hour a day telephone interpreting services. CyraCom Blue Phones are available on all inpatient units and throughout outpatient service areas.

For internal callers, pick up the handset, push a button and say the language that needs to be accessed. CyraCom phones are programmed with unit/department pin numbers. Or dial #1414 or 1-866-745-5010 from any NorthBay Healthcare phone. For external callers, dial #1-888-294-3600 and ask to be transferred to extension #1414. The caller will be connected to the CyraCom system.

To identify the patient/family language and dialect, reference the CyraCom quick reference cards posted in common areas. The telephone interpreting service will be able to assist with determining correct languages and dialects.

When using the CyraCom service, NorthBay staff is required to document in the patient's medical record the interpreter's identification number and the content of information interpreted.

Video Remote Interpreting (VRI), through Cyracom, is available for voice interpreting. A laptop with the needed software resides at each hospital campus and can be accessed by the social workers during day shift hours and by the Administrative Coordinators after hours. In addition, VRI is available on the inpatient/outpatient settings equipped with IPads with the Cyracom application.

The Language People is an on-site interpreting service providing interpreters for difficult or sensitive patient/family conversations. This service is available 24 hours a day. Social Services and the Administrator Coordinator are authorized to arrange for this service.

Hearing/Speaking Resources:
Video Remote Interpreting (VRI), through Cyracom, is available to patients with hearing impairments who require interpreting services (ie: American Sign Language). A laptop with the needed software resides at each hospital campus and can be accessed by the social workers during day shift hours and by the Administrative Coordinators after hours. In addition, VRI is available on the inpatient units/outpatient settings equipped with IPads with the Cyracom application.

NexTalk TTY services are available to patients by dialing (855) 778-8558 posted throughout the system. This will connect the caller with a relay operator that will connect the caller to one of the designated computers throughout the system, in the hospital and in outpatient areas.

Visual Resources:
For visually impaired patients, the health care staff will read materials to them, as appropriate, and/or, with the patient's permission, will engage patient's family and friends to participate in communication and education no differently than done with patients who have vision capabilities.

Documentation:
All communication involving interpreting services will be recorded in the patient's electronic medical record. Documentation will include the date, the time, the name of the agency, and an identifying name or number of the individual providing the interpretation.

Annual Review Responsibility:
The Director of Case Management will be responsible to ensure the transmittal of the annual review of the policy to the California Department of Public Health. The Director of Case Management will annually review posting of this policy on the NorthBay Healthcare website.

Effective Date: August 2019