Transforming interpretation at Yale New Haven Hospital
As the pandemic rages on, the hospital's language services department is continuing along a path away from in-person interpretation.
The changes to Yale New Haven Hospital’s interpretation services, used by thousands of local residents each year, came suddenly in October of 2019.
That month, the hospital system’s Department of Patient Experiences and Operations implemented a series of critical changes to internal policy on interpretation services. The hospital reduced the types of patient-provider interactions that qualified for in-person interpretation services. Remote interpretation services such as video and phone interpretation grew in use.
The policy switch and the fast timeline of its implementation sparked concern and confusion among many and started conversations between providers and administrators within the hospital. Some providers and employees questioned the sensitive types of patient-provider interactions where remote interpretation was being used.
Yet the conversation over the changes halted almost as abruptly as they started. In the waning days of March, as the daily temperatures began to jump above freezing, the coronavirus pandemic arrived in New Haven with a feverish pitch, forcing all other issues to take a backseat.
The public health crisis immediately demanded the absolute focus of Yale New Haven Hospital System, the city’s largest medical institution. All energies shifted quickly and completely to responding to the rates of infections that grew through April and May. The hospital transitioned numerous of its wings to serve the steady stream of COVID-19-positive patients and eliminated the many elective surgeries and traditional appointments that would usually fill up the hospital with in-person visits.
“With the pandemic, resources were allocated elsewhere,” said Dr. Stephanie Massaro, an attending physician for hematology and oncology at Yale New Haven Children’s Hospital and also assistant professor of clinical pediatrics. “This issue had to be tabled because [the] administration needed to respond to other faculties to assure the provider and patient safety, and I understand that.”
Yet as attention shifted focus, changes to the department of language services, which provides interpretation and translation services, have continued to show their effect. Access to in-person interpreters has become increasingly difficult, as the number of staff within the language services department has dropped. At the same time, the virtualization of health care through telehealth has normalized the expanded presence of remote interpretation services with some providers. Within the language services department, pushback to changes from numerous long-term employees has led to an exodus of staff. Inside the halls of many departments, a new normal — wherein remote services predominate over their traditional counterpart — has emerged.
The October policy changes included new triage guidelines that reduced the number of types of appointment or patient-provider interactions that qualify for the use of in-person interpretation services. YNHH Chief Experience Officer Joan Kelly told the News in February that the decision to enact changes to the system formed part of an institutional effort to streamline and expand services.
The decision in December came after legal pressure to reconsider a part of its services for deaf and hard of hearing patients. In 2018, a federal judge ruled that a number of Connecticut hospitals, including Lawrence + Memorial Hospital of the YNHH system, were not in compliance with standards for providing interpretation services for deaf and hard of hearing customers.
But the changes left Limited English Proficiency (LEP) patients more dependent on remote forms of interpretation services. It predominantly increased the use of video interpretation, carried out on iPoles — portable carts with screens as heads used to display video interpreting services. The demand for iPoles led to their scarcity and raised questions about access to remote interpretation services, according to Massaro. Besides the problem of scarcity, providers also criticized the disruptive nature of the new video services, which they said dropped calls, due to issues in broadband connectivity.
YNHH spokesman Mark D’Antonio did not directly respond to questions about the hospital’s record of video-call connectivity or broadband access. Still, he praised the new policy in an email and said that administrators implemented the new program to allow “employees more autonomy in setting their schedules by identifying needs in advance.”
But several current and former language services employees told the News that the lack of flexibility within the new operating system led to days where they sat idly — under-scheduled and underutilized. According to these employees, the new scheduling system regularly assigns interpreters only a limited amount of appointments each day. They added that it did not allow interpreters to reorganize their schedules or request different work when scheduled appointments cancelled. These employees also told the News that the changes have deflated morale and led to a split between management and numerous employees.
“What is the future for the department? Interpreters only by phone and video? Because I can’t see it any other way.”
“What is the future for the department? Interpreters only by phone and video? Because I can’t see it any other way,” a current employee of language services told the News. The employee asked their name be kept private for fear of retaliation from their employer.
YNHH did not respond directly to questions on the effect of the operating system changes to the work experience of employees.
Patients too immediately noticed the change. In February, News interviews with New Haven residents that required use of language services revealed that the use of remote interpretation services occasionally led to suboptimal experiences for patients.
One patient, Deli Velazquez, who originally hails from Mexico, told the News in February that she had trouble communicating through phone interpretation over multiple days when she went to the hospital to care for her ailing son in January. During that meeting, Velazquez struggled to communicate on behalf of her son, who was occasionally in too much pain to speak for himself.
Velzaquez said she found the interpretation phone service unintelligible and asked instead for an in-person interpreter, but was told that none were available.
For the next three days, Velazquez relied on the phone interpretation services despite no improvements in quality. She continued to voice her concerns over the service and was later assigned an in-person interpreter, but only at certain hours. She told the News that the concerns over interpretation contributed to her overall confusion over treatment options. That confusion and distress over her son’s health led her to eventually discharge her son from the hospital and opt to take care of him at home.
Several patients who spoke to the News in February, including Velazquez, characterized their interactions with remote interpretation services to be a drop in quality from their past experiences with in-person interpretation services. They struggled to hear the interpreter and the remote interpreter failed to fully convey their concerns to the doctors, those patients explained.
Still, in February, Kelly told the News that negative experiences with early patient experiences with the remote services did not indicate a change in quality. Instead, these complaints were symptoms of adjusting to a change, she argued.
The pandemic has brought an even larger amount of LEP patients in contact with virtual interpretation services. Since the onset of the pandemic, the hospital has only used remote interpretation services, often in the form of video, to communicate with COVID-19-positive patients.
One such patient, Wanda Roman, a New Haven resident originally from Puerto Rico, was admitted to YNHH as COVID-19-positive in April. During her week stay at the hospital, Roman interacted with providers exclusively using video interpretation services. While Roman felt that she understood everything her providers shared with her, she told the News she felt less confident asking for information on the status of her health and treatment beyond what she was told. When the screen on the iPole went off, Roman felt that her time to ask questions was over. In the past, Roman said she asked passing interpreters for help.
The city’s ever-growing Latino community, with a high percentage of foreign-born Latin American immigrants from Mexico, Guatemala, Ecuador, among others, have settled in large numbers throughout the Greater New Haven area and account for about a third of the total population today.
Spanish has remained the most prevalent language of request at YNHH accounting for 80 percent of the annual requests for language services in 2016.
STRIKING A BALANCE
Experts continue to disagree over the extent to which newer remote interpretation services should be used in the medical interpreting industry.
The shift towards an increased use in remote services is not unique to the Yale New Haven Hospital. As the demand for interpretation services increased throughout the United States, health care providers had to find methods to fulfill the ever growing and linguistically diverse requests for interpretation services.
Joumana de Santiago, manager of Interpretation Services for Lehigh Valley Health Network in Pennsylvania, told the News that while a shift towards remote services has often appealed to hospitals looking to modernize, it has sometimes caused difficulties.
According to de Santiago, for smaller hospitals with limited resources, using remote interpretation services can often be the most economically feasible manner to provide interpretation. Still, the lack of interpersonal interaction has convinced many providers and industry professionals that there are aspects of in-person interpretation that cannot be replaced by remote interpreter services, she added.
Jacqueline Ortiz, director of Diversity and Inclusion for ChristianaCare, a Delaware-based health care provider, said that while the foundational role of a medical interpreter is as a “conduit” of language, interpreters also have ethical and professional obligations to serve as clarifiers, mediators and advocates.
Ortiz added that in-person interpretation services provide the most conducive environment for an interpreter to manage all these roles successfully. She explained that in-person interpreters can be more effective readers of body language, silence and other forms of non-verbal communication. This makes them more likely to spot situations where lapses in communication are not verbally communicated by patients. She added that this is particularly important in overcoming differences in cultural norms or the intimidating nature of a hospital environment.
“The interpreter is the only person in the room that knows when a service is not being provided when it should,” Ortiz said. “It’s not that patients always know what to do. Sometimes they’re just stuck.”
“The interpreter is the only person in the room that knows when a service is not being provided when it should. It’s not that patients always know what to do. Sometimes they’re just stuck.”
—Jacqueline Ortiz, director of Diversity and Inclusion for ChristianaCare
Despite the turmoil of the COVID-19 pandemic, the hospital’s language services department has continued its transformation.
Since October, the number of employees within the department has shrunk by nearly half; former staff interpreters and translators have left, reducing the number of employees from 34 in October of 2019 to around 20, former and current employees of the department confirmed to the News.
Many of those that left did so because of the change, according to employees sourced by the News. Some resigned, others took early retirements. A few refused to return to work and were dismissed.
News interviews with nine former and current employees revealed that many of those exits were caused by a work environment cited as hostile and inconsiderate. Many of those who left the department had worked in it for nearly a decade.
“Someone has left the department during each month this year,” said a current language services employee on the exodus of colleagues during which the department has seen many months with multiple employee resignations.
The employee requested anonymity to discuss the happenings candidly with the News.
Several of the former employees told the News they left the department because they felt the department had undergone a transformation with little to no input from department employees or providers. Many felt that the department no longer valued them as a vital part of the healthcare team.
“I don’t think [Patient Experience and Operations management] took into consideration the experience [and] the quality of the service I was providing,” said Aura Marina James, a former YNHH interpreter of 15 years. “Because there was never a discussion [regarding the changes].”
James made the decision to retire early in March, citing hostile and inconsiderate responses from management on employee concerns over the changes.
YNHH did not respond to questions on the quick turnover of department employees nor on the number of in-person interpreters and translators it planned to keep on staff.
A CHANGE IN FOCUS
The pandemic switched many of the hospital’s subspecialties and clinics towards a telehealth-based form of services. By the end of April, the hospital had conducted 51,000 outpatient visits by telehealth.
In part, the switch to telehealth-based care has normalized the use of telehealth and video interpretation, even among providers who originally voiced their concern over the increased reliance on remote interpreting. Provider response to remote interpretation services softened during pandemic as many have, at least temporarily, come to accept the remote interpretation as inherent to the culture of ‘social distancing’ necessary during the pandemic.
At the same time, the switch to telehealth and the restrictions placed on most non-emergency, in-person care left the hospital below prior capacity, or the number of patients the hospital normally serves. Since the onset of the pandemic, this shift freed services that at normal capacity were harder to access. The postponement of elective surgeries and non-essential interments reduced the number of total patients at the hospital. The lack of competition for interpretation services improved the rate at which department’s needs were met.
As the hospital has returned to capacity, Massaro said she has begun to notice the same issues with the interpretation services that she noticed when the hospital was at full capacity before the pandemic.
iPoles too have remained in short supply in certain parts of the hospital. In the YNHH’s Trumbull clinic, the 20-room wing for clinical pediatrics has only one iPole for all providers to share, Massaro said.
“Now that we’re nearing the end of the pandemic, I think we’re returning to ‘you’re gonna need to wait one to two hours’ for an interpreter or ‘you may have to wait 10 or 20 minutes for your partner to finish using an iPole down the hall,’” she said.
(Yale Daily News)
From outside the hospital’s efforts to care for patients with the coronavirus, Massaro has continued to observe the effects of the policy changes in interpretation services on a normal basis. As an attending physician at Yale New Haven Children’s Hospital, part of her daily routine includes rounding — the daily communications between physicians, patients and family that occur for in-patients.
Massaro’s patients are often children with cancer, thus her interactions are often with the patients and the family members by their sides. She estimates that about 50 percent of her interactions with patients and families require interpretation services.
In New Haven, the demands for interpretation services are not likely to go away. Over the past two decades, the number of LEP patients using the hospital has continuously risen.
Thanks to Yale New Haven Hospital’s reputation, the hospital attracts LEP patients from different parts of the world. Still, like Velazquez, the majority of LEP patients that rely on the interpretation services at Yale New Haven Hospital come from one of the city’s migrant communities. Today, 14 percent of New Haven residents are foreign-born, according to data from DataHaven’s 2020 Neighborhood Profiles series. The current number of foreign-born New Haveners is twice what it was in 1990. As of 2017, 11 percent of New Haven residents reported a low level of English proficiency, according to the hospital’s Community Health Needs Assessment.
Several YNHH physicians told the News they prefer an in-person interpreter during occasions when delivering news that could lead to emotional conversations with patients and their families. According to Massaro, in-person interpreters better assist her to convey a “sentiment of concern and respect,” and ensure that families in delicate conversations are adequately cared for. Yet these physicians also emphasized that with in-patient services where patient conditions are more likely to remain stable, video-remote interpreting can work well.
Current employees of the language services department told the News that staff interpreter participation in in-patient services like rounding has fallen significantly since the department implemented the new triage guidelines late last year. The new guidelines instruct providers to use video interpretation services as the default form of communication for many in-patient interactions.
The current triage guidelines do prioritize the use of in-person interpretation services during “family discussions” and other types of interactions that involve sensitive conversations of life and death. But this is only guaranteed when the sensitivity of the issue is known in advance and when the provider files the request with anticipation.
Massaro said she believes the conversation over the state of interpretation services at the hospital will reignite at a future point, when hospital operations return to a more normal state.
“I think as we start to move back to our regular functionality we may see [the effect of] that change,” she said. “I can’t tell you if all the issues we had have been properly addressed because all our attention was with the pandemic.”
Correction, Sept. 15: This article has been updated with Joan Kelly’s correct job title. It has also been updated to better reflect the sentiment of James’ comments.