Advanced Effective Communication, Cultural Competence, and ...

A Roadmap for Hospitals
Appendix D: Laws and Regulations
(NIH), or other federal funds. Title VI protection generally
extends to all programs and activities of any health care entity
receiving federal financial assistance, whether or not the particular
program at issue has itself received those funds [2].
According to the HHS implementing regulation for Title VI,
a hospital that receives federal financial assistance may not,
based on race, color, or national origin:[3]
• Deny services, financial aid, or other benefits provided as a
part of health or human service programs
• Provide a different service, financial aid or other benefit,
or provide them in a different manner from those provided
to others under the program
• Segregate or separately treat individuals in any matter related
to the receipt of any service, financial aid, or other benefit
Revised HHS LEP Guidance—Effective
Practices for Title VI Compliance
The Revised HHS LEP Guidance provides an analytical framework
that hospitals may use to determine how to best comply
with obligations to provide meaningful access for individuals
who are limited English proficient to the benefits, services, information,
and other important portions of their programs and
activities [4].* While designed to be a flexible and factdependent
standard, the starting point for an individualized
LEP assessment should balance the following four factors:
1. The number or proportion of LEP persons eligible to be
served or likely to be encountered by the program or
grantee
2. The frequency with which LEP individuals come in
contact with the program
3. The nature and importance of the program, activity, or
service provided by the program to people’s lives
4. The resources available to the hospital and costs
The Revised HHS LEP Guidance seeks to suggest a balance
between allowing access by LEP persons to critical services
while not imposing undue burdens on small business, small
local governments, or small nonprofits.
Highlighted in the next section are several tips and tools contained
in the Revised HHS LEP Guidance, including how to
develop an effective LEP implementation plan, interpreter
competency, and translation of written documents.
Typical Elements in Effective LEP
Implementation Plans
While an LEP implementation plan is not required, should a
hospital decide to develop such a plan, the Revised HHS LEP
Guidance document provides five elements for making the
plan most effective: †
1. Identify LEP individuals who need language assistance.
The first two factors in the analytical framework require
the hospital to assess the number or proportion of LEP
individuals eligible to be served or encountered and the
frequency of encounters. Accordingly, this step requires a
hospital to understand how it will identify LEP persons
with whom it has contact and/or could have contact.
2. Describe language assistance measures. Include information
about the ways in which the hospital will provide language
assistance. For instance, hospitals may want to include
information on at least the following items:
• Types of language services available
• How staff can obtain those services
• How staff should respond to LEP callers
• How staff should respond to written communications
from LEP persons
• How staff should respond to LEP individuals who have
in-person contact with hospital staff
• How to ensure competency of interpreters and
translation services
3. Train staff. Construct a process for identifying staff who
need LEP plan training, design a plan for training them, and
determine the desired outcomes of the training. An effective
LEP plan may include training all staff on LEP policies and
procedures and staff who have contact with the public to
work effectively with in-person and telephone interpreters.
4. Provide notice to LEP persons. Describe the process by
which the hospital will notify LEP persons the hospital
serves or, to the extent that a service area exists, LEP
persons that reside in its service area and are eligible for
services of the LEP services that are available.
5. Monitor and update the LEP plan. Identify a process for the
hospital to monitor its implementation of the LEP plan and
* Note that the HHS LEP policy guidance is not a regulation but rather a guide, and that portions excerpted in this section are not reproduced in
their entirety. The entire document is available at http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/policyguidancedocument.html; a
summary of the guidance is available at http://www.hhs.gov/ocr/civilrights/resources/laws/summaryguidance.html. The Revised HHS LEP Guidance
“Q&A” can be found at http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/finalproposed.html.
† See full discussion at pp. 17–19 of the HHS LEP Guidance.
66