This measure is used to assess the percentage of limited English-proficient (LEP) patients receiving both initial assessment and discharge instructions supported by assessed and trained interpreters or from bilingual providers and bilingual workers/employees assessed for language proficiency.
Interpreter services are frequently provided by untrained individuals, or individuals who have not been assessed for their language proficiency, including family members, friends, and other employees. Research has demonstrated that the likely results of using untrained interpreters or friends, family, and associates are an increase in medical errors, poorer patient-provider communication, and poorer follow-up and adherence to clinical instructions. The measure provides information on the extent to which language services are provided by trained and assessed interpreters or assessed bilingual providers and bilingual workers/employees during critical times in a patient’s health care experience.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
The number of limited English-proficient (LEP) patients with documentation they received the initial assessment and discharge instructions supported by trained and assessed interpreters, or from bilingual providers and bilingual workers/employees assessed for language proficiency.
Note: The determination of "qualified (assessed and trained) is consistent with guidance provided by The Joint Commission, The Office of Minority Health CLAS standards; and the Office of Civil Rights.
Citations: The Joint Commission (2011), Patient-Centered Communication Standards for Hospitals, Standard HR.01.02.01; available at http:www.jointcommission.org/Advancing_Effective Communication/
65 Fed. Reg. 80865 (Dec. 22, 2000) (Department of Health and Human Services: National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care); available at http://www.omhrc.gov/clas
65 Fed. Reg. 52762 (Aug. 30, 2000) (Office for Civil Rights: Policy Guidance on the Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency); available at http://www.hhs.gov/ocr/lep/preamble.html
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1.15 Denominator
Total number of patients that stated a preference to receive their spoken health care in a language other than English.
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Exclusions
Exclusions:
•All patients stating a preference to receive spoken health care in English.
•Patients who leave without being seen.
•Patients who leave against medical advice prior to the initial assessment.
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Person and Family-Centered Care Project 2016-2017Initial EndorsementLast UpdatedRemoval Date
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StewardDepartment of Health Policy, The George Washington UniversitySteward Organization POC EmailSteward Organization Copyright
© 2009 Department of Health Policy, George Washington University School of Public Health and Health Services.
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Risk Adjustment
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6.1.2 Current or Planned Use(s)
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