From mandate to practice: How language access policies affect Spanish-speaking patients and the health care professionals who serve them

Health care organizations are adopting policies and practices to meet the needs of limited English proficient (LEP) patients and comply with the Civil Rights Act of 1964. It is uncertain which policies and practices are actually implemented and of benefit. Using Diffusion of Innovations as a framework, this case study explored practices used to enhance language access in a large urban medical center that serves a diverse patient population, including many Spanish speakers. Methods included participant observation and interviews with administrators, providers, nursing and support staff, and Spanish speaking patients in five clinics. Key topics included: (a) perceptions of language access by patients and employees, (b) formal and informal strategies employed to provide meaningful language access, and (c) results from implementing these strategies. The health care organization's formal practices to increase language access consisted of hiring bilingual employees, contracting with telephonic interpreter services, and hiring medical interpreters. Despite these efforts, structural and contextual problems persisted, including: (a) care based on inaccurate or incomplete information, (b) delays in care due to inefficiencies in the system, and (c) language barriers throughout the clinic visit. Other challenges included discrimination and prejudicial attitudes toward patients, and alienation among staff. To respond to LEP patients, health care professionals employed informal strategies such as using co-workers, asking family members to interpret, and making do with gestures to overcome language barriers. Gaps in language access remain, and are implicated in organizational inefficiency and potentially poor clinical care. Findings have implications for developing more culturally competent health care organizations, and improving policies and practices for delivering care to LEP patients.