What made CultureSmart’s first-ever pre-certification study group a certifiable success? A curriculum designed to prepare medical interpreters for certification exams. Sixty-five medical interpreters speaking Spanish, Portuguese, Haitian Creole, Russian, and Vietnamese. Eight moderators with training and interpreting backgrounds. Hours of collegial interaction in small groups on four Saturdays. Plus epic studying.

The unique program targeted working interpreters, many of whom received training earlier in their careers. Lots of experienced interpreters, though, don’t work with a full range of medical fields and terminology in their day-to-day work. Carla Fogaren, RN, system director of diversity initiatives and interpreter services at Steward Health Care System, who initiated the study group program with CultureSmart to help her team study for exams, said her interpreters were “very, very pleased with the program.”

Carla says vocabulary was a big point of interest for Steward interpreters since certain specialties—such as genetics—pose high risk for mistakes because interpreters are rarely exposed to them. Spanish interpreters found an especially rich environment for broadening their linguistic and cultural competence, Carla says, thanks to a diverse group of interpreters who gained “a lot more depth as far as colloquial expressions and what’s used in different countries.”

Carla also praised moderators’ patience and ability to encourage professional growth among interpreters and was pleased with CultureSmart’s flexibility in compiling a customized curriculum to prepare interpreters for certification tests that are already being implemented. Carla says Steward wanted to “make sure that we always stay ahead of the curve” in expanding the interpreter team’s competencies.

Jane Kontrimas, a CultureSmart language coach who works as a Russian interpreter and as trainer coordinator for interpreter services at Beth Israel Deaconess Medical Center, echoed Carla’s observations: the group of Russian interpreters Jane moderated was eager to review and expand their vocabularies. Bringing together groups of interpreters with varied histories was especially useful, says Jane, “These were experienced interpreters but for a few situations, they were glad to bounce ideas off of somebody else or each other.”

CultureSmart’s team of curriculum developers and language coaches designed a series of four sessions that presented:

•       A targeted curriculum and unique participatory workshop style
•       Opportunities to practice with linguistically and culturally diverse colleagues
•       A training facilitator for each language group
•       Intensive, focused small group coaching at each session
•       Plenty of time for all that epic studying between the four Saturday sessions

Cheila Mageste, Portuguese Interpreter

Sixteen hours in the classroom plus individual studying made the program “intense but really nice,” says Cheila Mageste, an interpreter of Portuguese who works at Cape Cod Healthcare. “I feel like I was studying to be a nurse,” says Cheila, “I love it, the way they taught us, all the material, I love it.” Cheila, who signed up for the program independently, thinks she learned more in the pre-certification prep group than when she studied medical interpreting 11 years ago, when she was becoming an interpreter.

The pre-certification prep program presented medical terminology plus logistics and techniques for interpreting. The sessions used frequent role plays that created unique opportunities to simultaneously practice, learn from expert trainers’ critique, and observe colleagues’ techniques. Cheila, who called the methodology “wonderful,” enjoyed all the topics. Detailed discussions of body systems, pathology, medical procedures, and treatments covered such subjects as diabetes, appendectomy, colonoscopy preparation, coronary artery bypass surgery, pacemakers, ectopic pregnancy, cancer, and hydrocephalus.

Ongoing professional growth, notes Jane, who has interpreted for nearly 30 years, is such an important part of an interpreter’s responsibilities that it’s included in professional standards, such as the National Council on Interpreting in Health Care’s National Standards of Practice for Interpreters in Health Care. “We can all expand our horizons if we work hard enough,” she says.

Interpreters working at from Brockton Hospital, Cape Cod Healthcare, Caritas Christi Health Care (now Steward Health System), Lowell General Hospital, and SSTAR in Fall River participated in the course.

As the third leading cause of death in the United States, stroke affects all our lives and is an important topic for medical interpreters to understand. Stroke is also extremely complex, with numerous risk factors, warning signals, and types.

On Saturday, March 5, 2011, CultureSmart will host a medical interpreter training workshop with Judith Welch Clark, RN, BSN, the stroke service nurse at Boston Medical Center. Judith will discuss critical aspects of stroke – from risk factors to ongoing therapies after release – and look at the interpreter’s roles in caring for stroke patients.

The interview below introduces you to Judith and her tremendous clinical knowledge of stroke. We’ve bolded key terminology, linking some words to further information. To join us on Saturday, March 5, please visit this link to register.

1. What are the primary types of stroke? What are the most common causes and risk factors for stroke?

There’s embolic stroke, where the clot comes from a source other than the brain: it could be from the heart or carotid artery. The other type of ischemic stroke is thrombotic, from a localized source, cerebral arteries that are diseased or damaged. Hemorrhagic strokes are intracerebral, which could be from taking Coumadin, or subarachnoid, usually from an aneurysm or an arteriovenous valve malformation.

We manage stroke by managing risk factors. High blood pressure is the biggest cause so when patients come in, we monitor their blood pressure. We teach smoking cessation. Smoking affects your vascular function: it makes the vessels weaker. Diabetes and high blood cholesterol are important factors. Atrial fibrillation is another factor, as is illegal drug use.

2. What difficulties do providers face when discussing risk factors and lifestyle changes with patients?

Language barriers and cultural differences. With recovery, people often seem to feel that ‘Okay, I had the stroke, I’m going to do a good job.’ They get better, they’re taking the meds to make them better. And they are better: they’ve lost weight, they’ve exercised, and then they go off their meds. One of our biggest concerns is that they don’t understand that these meds are for the rest of their life. In our population, a lot of people are homeless or immigrants, and they don’t have health insurance, and a lot of the copays for the meds are very high.

3. Do you have any special advice for calling an ambulance in a case of suspected stroke?

When they call, people should say that they’re experiencing stroke symptoms. We teach patients about recognizing stroke symptoms using “FAST”: F=Facial droop, A=Arm movement, S=Speech abnormalities, and T=Time. Other symptoms could be lack of feeling, tingling, or sudden blindness on one side.

Time is very important. I tell people to call now because the EMS system is trained for triage. A stroke is considered a cardiac arrest. Patients go to the top of the line if they’re having stroke symptoms. We have a lot of time targets to meet in the Emergency Department with stroke patients, so it’s important to call 911 immediately if anyone has symptoms. If they show up within 3.5 hours of symptom onset, they may be eligible for a clot-busting drug called tPA.

4. How do providers assess patients suspected of having had a stroke?

Our physicians use the NIH Stroke Scale. It takes about eight minutes to do, and it’s important for interpreters to know. We ask the patient to do certain things, such as touching a finger to the nose, to help to determine where the stroke is. Certain symptoms go with different parts of the brain. Another symptom is sudden onset: stroke is usually sudden. We also get a history, both to determine when the patient was last without symptoms and because certain diagnoses ahead of time make you more at risk for a stroke.

5. What typical tests and analyses are conducted in the hospital? Is there a test that’s considered most definitive?

There’s some that we do right away: CT scan of the head, coagulation studies, and electrolytes, BUN, and then creatine. Then we do a urinalysis and a tox screen, kind of a drug screen for people. Later on that day we usually do an MRI, and then the next day we check cholesterol levels and HGBA1C. Then we do an echocardiogram. An MRI will tell you if you had a stroke, but an MRI doesn’t always show it until later so we don’t rush in most cases. We do the CT to make sure there’s no bleeding in the brain.

6. What are the most common treatments for patients immediately after a stroke, while in the hospital?

If they meet the criteria, they might be able to be given tPA. Interpreters are asked to help obtain consent for tPA because it puts patients more at risk for bleeding. A lot of times patients can’t talk so it’s very important that the family understands. The decision for tPA needs to be made quickly. The time target would be start the tPA within 60 minutes of crossing the ED’s threshold, so there’s no time to speak with everyone in the family. Sometimes it is a life or death matter, so it’s good to discuss in advance who would be the spokesperson and how aggressive they would want care to be, keeping in mind what the patient would want.

7. What are some of the typical therapies that patients undergo after hospitalization?

The most important would be antiplatelet therapy, aspirin, Plavix, or Aggrenox, or sometimes Coumadin, an anticoagulant. Other common meds are antihypertensives, to lower blood pressure, and statins, for cholesterol. Physical therapy (PT), occupational therapy (OT), and speech therapy might also be recommended. Most people need both PT and OT. A high percentage go to rehab hospitals after acute hospitalization.

8. What should interpreters and family members know about transferring stroke patients to home after hospitalization?

They need to be aware of ‘deficits’ and safety concerns. Some people are blind or have what’s called ‘neglect’ on one side, and they don’t realize they have this. OT teaches them about that. Some people lose sensation after a stroke so they need to be especially careful near the stove and hot and cold water. Some people are aphasic and lose their speech but others have cognitive deficits, like not being able to do math or read anymore. And you don’t find out until they come home.

9. What else do you think medical interpreters should consider when interpreting for stroke patients?

There are some common complications after stroke, like aspiration pneumonia and deep vein thrombosis. Some people who aren’t able to swallow without aspiration might need a feeding tube. Some of the things we need to teach patients in patient education before they leave are stroke warning signs and symptoms and how to call 911. We also talk about the meds we send them home with, risk factors that might have caused their stroke, and the need for follow up with their doctors. We stress to start taking their meds before talking with their doctor. For prevention: lose weight, eat a healthy diet, eat enough fruits and vegetables, enjoy regular physical activity, limit alcohol, take medicine as prescribed, and know what your blood pressure should be. Ideals can vary, so ask your physician where your blood pressure should be.

Languages: Spanish, Portuguese, Vietnamese, Khmer, Polish, Korean, Japanese, Italian, Lithuanian, Ukrainian, Russian, Cantonese, Mandarin, and more.

Minimum Requirements for Medical Interpreters:

• Interpreter needs to possess a Healthcare Interpreter Training Certificate of Accomplishment – 40 hours
• 1 year of experience in a healthcare setting as a medical interpreter is a plus but not required
• High school diploma or equivalent

Minimum Requirements for Legal Interpreters:

• Interpreter needs to possess a Legal Interpreter Training Certificate – 60 hours
• 1 year of experience as a Legal Interpreter
• Bachelor’s degree is prefered, or an adequate combination of education and experience in the field

Also interpreters need to possess a high level of customer service and a positive approach, general knowledge of cultural backgrounds of patients to be served, good interpersonal, organizational, and time-management skills.

Contact Information: Send your resume to Fatuma Hassan at
fhassan@embracingculture.com or you may fax it to: 781-729-1217.
You can also reach her by phone at 781-729-3736 X127.

The Certification Commission for Healthcare Interpreters offers two examinations for healthcare interpreters. Applications are now being accepted for testing dates in 2011.

Associate Healthcare Interpreter (AHI)
The CCHI Associate Healthcare Interpreter™ credential is the first credential, the foundation credential for all healthcare interpreters. Once a healthcare interpreter receives his/her CCHI Associate Healthcare Interpreter™ credential, s/he is eligible to apply for a language specific credential in one or more languages in which s/he interprets.

The CCHI Associate Healthcare Interpreter™ Examination is a computer-based, 100-question, multiple-choice exam in English that covers the basics of healthcare interpreting and focuses on the following five categories of knowledge, skills and abilities:

• Managing an Interpreting Encounter
• Healthcare Terminology
• Interact with Other Healthcare Professionals
• Prepare for an Interpreting Encounter
• Cultural Responsiveness

Spanish Certified Healthcare Interpreter™ (CHI)
The CCHI Spanish Certified Healthcare Interpreter™ certification consists of a two part examination that covers the basics of healthcare interpreting and a demonstration of interpreting skills in both consecutive and simultaneous interpreting. A healthcare interpreter will take the AHI™ examination and the CHI™ Spanish examination, an oral/performance exam that includes a number of vignettes testing consecutive and simultaneous interpreting plus sight translation via headsets with oral answers.

The CHI™ Examination is an oral performance exam that includes a demonstration of interpreting skills in both consecutive and simultaneous interpreting. It focuses on the following two categories of knowledge, skills and abilities. The examination is conducted online via computer and is scored by two independent raters.

• Interpreting in a Healthcare Encounter
• Sight Translate/Translate Healthcare Documents

For complete details and to apply online, please visit the CCHI web page.

At CultureSmart, we’ve been thinking about – and preparing for – medical interpreter certification for years. The Q&A in this blog entry offers background on healthcare interpreter certification plus our thoughts on how certification will benefit interpreters, patients, and the health care industry.

What is the status of medical interpreter certification in the U.S.?
National certification is a long way off, but there’s a nation wide wave of interest in certification, thanks to a movement that started several years ago. Currently, the largest impediment to the adoption of certification is that most stakeholders – hospitals, providers, patients, even interpreters – either don’t fully grasp what medical interpreter certification would mean or don’t see justification for it.

In addition, the powers-that-be in health care – decision makers, funders and even, to some extent, regulatory and accreditation agencies – were not or are not completely “on board” with certification. That’s partly because the status quo feels familiar and comfortable, even though it has some problems. We’ve seen similar situations: many providers favor continuing to use ad hoc interpreters, essentially bilingual people who happen to be nearby, rather than qualified interpreters, who must often be booked in advance.

Unless there’s lots of advocacy – as I think we’re seeing now – you won’t get buy-in from stakeholders. The squeaky wheel gets the oil.

Why are there two groups – The Certification Commission for Healthcare Interpreters and The National Board of Certification for Medical Interpreters – working on certification?
The push for certification began as a coalition several years ago but it split because of conflicting approaches. The approach of The National Board of Certification for Medical Interpreters is “Let’s get certification now.” This group believes that, regardless of whether a comprehensive process is in place, it’s best to start certification and let everything else follow.

The Certification Commission for Healthcare Interpreters had the philosophy that the field isn’t yet ready for certification. Interpreter preparedness is uneven and, nationally, most organizations aren’t convinced of the benefits of using screened, trained, qualified interpreters. Another issue is that national standards, though available, aren’t consistently applied. The Certification Commission’s approach was to continue the work started by the National Council on Interpreting in Health Care to methodically develop awareness in the field, gradually disseminate and implement standards nationally, before launching a national certification process.

As a trainer of interpreters who visits many states, I find that many staff members who interpret display little awareness of the interpreter’s role. We usually spend almost four hours in most of our introductory training programs deconstructing the interpreter’s role and dispelling certain myths before we move on to exploring the interpreter’s functions.

I think the Certification Commission’s approach – methodically creating awareness and developing tools, steps, and milestones that will eventually lead to certification – is a sensible, rational approach. In reality, though, the National Board started registering candidates for pilot certification in 2009. Then the Certification Commission followed suit almost immediately in 2010. Today, both approaches are being implemented simultaneously. This is a big development for the field because certification is so important, but I can’t predict how much of an immediate or long-term effect it will have on interpreters’ careers or patients’ lives.

What do you think about medical interpreter certification? Is it necessary?
I think certification is validation for the profession. Having been an interpreter for almost 20 years, I see progress in recognizing the importance of professional interpreters. I think certification is the last challenge to gaining recognition for the profession. I think it could help to standardize interpreters’ work.

In the U.S. there are geographic clusters where national and local standards are often followed. However, if you look at the interpreting profession overall, interpreter preparation and qualifications vary greatly. So do stakeholders’ expectations: they range from expecting family members to interpret to requiring that interpreters have advanced degrees in addition to training. Certification would help eliminate those discrepancies.

I believe that one of our problem is that we’ve become too fixated on the word “certification.” Unfortunately, it has eclipsed our efforts to develop and observe standards and codes. Ten years ago, while I was working at the Massachusetts Department of Public Health’s former Office of Refugee and Immigrant Health, we helped to establish, disseminate and enforce interpreter standards. Today, interpreters in Massachusetts generally abide by the same standards and codes. At CultureSmart, national standards and codes from CHIA, IMIA and NCIHC have always been an integral part of our curriculum.

How will certification change the way medical interpreters work?
I think certified interpreters will work with more confidence. They’ll feel more recognized and more empowered, which will justify their presence and role in the clinical team. Interpreters often work in the shadows, and they don’t always feel empowered to assert themselves as interpreters. I also think the pay of interpreters will rise – interpreters might be most excited about that. Certification will also ensure that interpreters no longer compete with family members and unqualified, untrained, ad hoc interpreters.

How might certification benefit providers, patients and health care facilities?
The biggest way certification will benefit providers is by easing pressure in working with LEP patients. Communication is crucial to providers’ work: if communication is hindered, providers face more risk of making wrong decisions and diagnoses, and arriving at negative outcomes and adverse events. An interpreter can be the weakest or strongest link in the provider-LEP patient relationship. If an interpreter is not screened, trained, and qualified – which certification should ensure – s/he is more likely to convey incorrect information or omit something as this has been shown in several studies.

On the patient’s side, patients’ rights would more likely be fully observed when there’s a certified interpreter present: everything the patient expresses will, presumably, be interpreted exactly as it is said, without any omission, additions or changes of information, thus enabling better communication with their providers. Interpreter certification also means interpreters have demonstrated they possess the necessary vocabulary for interpreting doctor-patient communications.

For healthcare facilities, some of the benefits are the same as for providers: the interpreter is more integrated in the clinical team. That leads to higher efficiency in the delivery of care, which leads to savings in the cost of providing care to an LEP patient. If you look at healthcare facilities’ concerns with risk management and care for LEP patients, you see that the potential for miscommunication exposes facilities and providers to the risk of giving a patient the wrong treatment. When you have certified interpreters, there’s a far greater chance that medical history will be more complete, reducing risks to both the facility and the provider. Certifying interpreters would also shift liability for interpreter errors from the facility and provider to the interpreter, who would be required to purchase insurance, as legal interpreters who work in the federal court system already do.

Are there any downsides to certifying interpreters?
I think it depends on whom you ask. As a trainer and interpreter, I can’t see any downsides to certification. However I think it will take time to become a reality. I believe implementing certification before the field is ready may lead to people rushing or focusing on the word “certification” at the expense of qualifications and standards. It’s taken years for healthcare organizations to universally adopt standards that are already available. A certification test is not a substitute for training or building awareness or getting buy-in from all the stakeholders involved in caring for LEP patients. Moving certification forward too quickly could lead to substantial problems later if the process doesn’t establish a system that provides solid rationale and stable support for national certification. Also, interpreters may become legally liable for their errors and omissions and may be required to carry professional liability insurance. That is a small price to pay for the many benefits that come with the official recognition that certification would bring.

How is CultureSmart getting ready for certification?
CultureSmart has been training interpreting staffs in national standards, national codes of ethics, medical vocabulary and other certification exam topics for 15 years. The topics –especially national standards- function as a common foundation for the profession. In my opinion, only when we all have a common understanding about the role and necessary qualifications of the interpreter can we say, “Okay now we’re going to test to be sure your knowledge and skills meet national standards.”

On Saturday, September 11th, in collaboration with Caritas Christi Health Care System, we launched a first in the nation program designed to prepare interpreters who speak Cape Verdean Creole, Haitian Creole, Portuguese, Russian, Spanish and Vietnamese to prepare for the written and eventual oral portion of the certification exams currently available. Seventy fulltime interpreters working at nine healthcare facilities in greater Boston are attending. The program, called “Pre-Certification Study Group” has a prescribed list of topics to be covered in the span of two months. Average group size is about 10, and the trainees are separated by language, to cover bilingual vocabulary. We’re excited about the course and look forward to hearing from other healthcare institutions that are interested in offering similar training. We will offer this program in the winter of 2011 in other areas and for other languages as well.

The course, called The Essential Piece™, is taught by CultureSmart™ professional trainers and is geared toward fluent bilingual speakers of English who also fluently speak Haitian Creole, Portuguese or Spanish, and wish to become medical interpreters. CultureSmart’s Essential Piece™ curriculum uses realistic role-plays and lively discussion so interpreters develop the skills and knowledge base, including medical terminology, they need to deliver accurate, complete interpretation in healthcare settings. Upon completing the 45-hour course and passing the final exams, candidates will receive a medical interpreter certificate.

Classes will be held on Saturdays from 9 a.m. to 2 p.m., from March 5 through May 14, 2011. The course costs $695, including tuition, training materials and exams. Class size is limited. Registration will be on a first come, first serve basis. To qualify to attend this training program, participants are required to demonstrate language proficiency in English and Haitian Creole, Portuguese or Spanish, and have one or more years of college or technical school education. Current or previous work experience in healthcare settings is ideal, but not required.

“I’ve been teaching CultureSmart courses in Hunterdon County for several years and have always been impressed with the thoroughness and rigor of CultureSmart’s curriculum. Our trainees rave about the experience. The courses are constantly being updated to include healthcare industry changes, and they also reflect a knowledge of important issues facing people who work as medical interpreters in New Jersey,” says Maria V. Bononato, CultureSmart lead trainer, New Jersey.

For course details or to register, go to http://www.culturesmart.com and select The Essential Piece™ at Riverview Medical Center course. Please call Maria V. Bononato at 908.310.6302 with any questions.