Advanced Effective Communication, Cultural Competence, and ...

A Roadmap for Hospitals
Appendix C: New Joint Commission Requirements
HR.01.02.01:
Explanation of Revision
It is not appropriate to rely on untrained individuals as the
primary source for bridging communication barriers during
medical encounters with individuals who are deaf or speak a
language other than English. Requirement HR.01.02.01,
EP 1, requires hospitals to define staff qualifications specific
to job responsibilities. Note 4 in EP 1 requires hospitals to
specifically ensure that individuals who provide interpreting
or translation services in the hospital have defined
qualifications and competencies. The research literature
demonstrates that relying on untrained individuals as
interpreters is more likely to result in misinterpretation [1, 2],
lower quality of care [3], or could even contribute to an
adverse event [4, 5]. Untrained individuals—including
family members, friends, other patients, or untrained
bilingual staff—should not be used to provide language access
services during medical encounters. It may be appropriate to
use untrained individuals for social conversations or to convey
or receive simple messages, provided that the messages or the
use of such untrained individuals do not infringe upon the
patient’s confidentiality.
In addition to language proficiency, individuals used to interpret
or translate also must possess a set of skills and follow professional
practice standards and a code of ethics.* Appendix E
(page 82) contains resources with further information about the
skills, standards, and ethics of interpreting and translating. It is
important to recognize that qualified interpreters may not be
available at every encounter. Hospitals have many options for
providing interpreter services, including using qualified bilingual
staff, hiring full or part-time professional interpreters, contracting
for interpreter services directly with an individual interpreter
or through an agency, or through the use of volunteers who are
approprately qualified. Regardless of the relationship, individuals
who provide these services must be competent and proficient in
both the target language and English. For more information
about providing interpreter services, see Workforce (page 37)
and Provision of Care, Treatment, and Services (page 39) in
Chapter 6: Organization Readiness and Appendix E: Resource
Guide (page 80).
The requirement to provide qualified language access services
reflects current law and regulation. Requirements for the provision
of interpreter and translation services is covered by the
Americans with Disabilities Act, Section 504 of the Rehabilitation
Act and Title VI of the Civil Rights Act.
For more information about these laws, see Appendix D: Laws
and Regulations (page 67).
Self-Assessment Guidelines
• A job description for interpreters includes defined competencies
such as language proficiency (in target language
and English), skills required, and training needed.
• Human resources files for individuals who are used to interpret
include evidence of their competency assessment as
outlined in the job description.
• Interviews with individuals used to interpret include discussion
about training, experience, and qualifications.
• For contracted interpreter services (either via phone,
video, or in person), the hospital receives assurance that
the contract includes information about how the service
provider defines competencies consistent with your hospital’s
defined expectations. (Joint Commission Leadership
Standard LD.04.03.09 specifically addresses the provision
of contracted services within the hospital.)
Recommendations from the Roadmap
❑ Integrate unique patient needs into new or existing
hospital policies.
❑ Ensure the competency of individuals providing language
services.
Provision of Care, Treatment,
and Services (PC)
The PC chapter focuses on the integrated and cyclical process
that allows care to be delivered according to patient needs and
the hospital’s scope of services. The complexity of providing
care, treatment, and services through this process often demands
an interdisciplinary collaborative approach and a mutual effort
from those who work in the organization to coordinate care in a
manner that is conducive to optimal patient outcomes, quality,
and safety.
PC.02.01.21:
Explanation of Revision
The new Standard PC.02.01.21 emphasizes the importance of
effective communication between patients and their providers
of care, treatment, and services. Research has shown that effective
patient–provider communication is necessary for patient
* Consult the National Council on Interpreting in Health Care, the Registry of Interpreters for the Deaf, and the American Translators Association for
additional guidance on the qualifications and competencies for language interpreters and translators.
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