Joint Commission standards
for language access

How to create a Joint-Commission-compliant language access program

Preparing for a Joint Commission survey can be stressful, and there’s a lot of information to unpack. We want you to feel confident about your language access program whenever the big day arrives.

That’s why we went through the Joint Commission’s 800+ page manual to find and expand on language access standards. We’ve broken everything down into 6 simplified steps to help prepare your facility or health system comply with the Joint Commission standards.

Step 1:
Research

Step 2:
Plan

Step 3:
Prepare the staff

Step 4:
Collect Data

Step 5:
Inform

Step 6:
Provide Care

Step 1: Research

What does your patient population look like?

Your community’s diversity will help you decide what kind of language services and communication support your facility needs.

Standard

RI.01.01.03 The hospital respects the patient’s right to receive information in a manner the patient understands.

Elements of Performance (EP) 2. The hospital provides language interpreting and translation services. Note: The hospital determines which translated documents and languages are needed based on its patient population.

Who is your hospital serving?

There are many demographic data sources for race, ethnicity, language, sexual orientation, and disability to help you determine who makes up your local community.

For the most accurate picture, look at data within the last 3 to 5 years.

Places to look:

US Census Bureau figures
local school enrollment profiles
voter registration records
public health department databases

You can also conduct focus groups or interview community leaders to identify demographic changes and community needs.

Fulfill two requirements at once – research the top 15 languages

Section 1557 of the Affordable Care Act also requires you to post notices in the top 15 languages in your state.

Standard

RI.01.01.03

EP 1. The hospital provides information in a manner tailored to the patient’s age, language, and ability to understand.

How to support a patient’s ability to understand

Over a quarter of Americans struggle with literacy: 42 million Americans cannot read, and 50 million adult Americans read at 4th or 5th-grade reading levels. Less than a quarter of the American population feel comfortable reading and comprehending materials related to their health. When research firm PRC conducted its National Health Survey of 1,000 adult Americans, it reported that 23.3% of surveyed Americans gave one or more of these responses:

Seldom/never find spoken health information easy to understand
Always/nearly always need help reading health information
Seldom/never find written health information easy to understand
Not at all confident filling out health forms

A review of 10.7 million Medicare records identified medical misunderstanding and miscommunication as the primary driver of unnecessary readmissions. When developing admission or other forms, patient education materials, or discharge instruction, you can work with a translation company to change your materials into plain English to improve understanding and increase positive health outcomes among your patients.

Step 2: Plan

Create a language access strategy for your hospital

Your strategy should include how your organization will communicate important information both verbally and in writing.

STANDARD

RI.01.01.03

EP 2. The hospital provides language interpreting and translation services.

Note: Language interpreting options may include hospital-employed language interpreters, contract-interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video.

Options for language interpretation

Interpretation – converting spoken and sign languages into other spoken languages

The Joint Commission leaves how to provide language services up to your organization. Which modes you use may depend on your budget and your hospital’s needs. You may want to create a list of language interpretation options and then develop supportive reasons to discuss with your decision-makers.

Options include:

Bilingual staff or providers
Staff interpreters
On-site interpreters from an agency
Remote interpreters – both audio-only and video

Your plan may include a mixture of language services to cover 24 hours a day, seven days a week, and for various circumstances.

language access plan graphic for hospitals

Options for translation and localization

Translation – converting written text from one language into the written text of another language.

Determine which documents need to be translated into which languages to meet the needs of your patient population.

This could include vital and non-vital materials such as:

Vital Documents

Informed consent documents
Complaint forms
Information about free language assistance programs or services
Notices of eligibility criteria for, rights in, denial or loss of, or decreases in benefits or services
Intake forms that may have clinical consequences

Non-Vital Documents

Menus
Third-party documents, forms, or pamphlets distributed as a public service
Large documents such as enrollment handbooks
General information intended for informational purposes only

Finally, incorporate language services information into new or existing hospital policies and procedures—you can provide these documents to the Joint Commission when they come to your facility.

Sample Strategy For Hospital Staff

When to use in-person interpreting

Spanish, Mandarin, Somali (your hospital’s top 3 languages)
- Staff interpreters: Monday – Friday, 7 am-7 pm
Spanish, Hindi, Portuguese, Haitian Creole
- See list of qualified bilingual care providers (See “how to make sure my staff and bilingual providers are qualified to interpret” below)
For unique scenarios, such as terminal diagnoses or scheduled appointments, please contact the hospital’s language services department to book external vendor on-site interpreters

When to use vendor telephone or video interpreting

Spanish, Mandarin, and Somali, and outside staff interpreter hours
Hindi, Portuguese, and Haitian Creole, and qualified providers are unavailable or busy
Other languages for routine scenarios or if an on-site interpreter isn’t available

STANDARD

RI.01.01.03

EP 3. The hospital provides information to the patient who has vision, speech, hearing, or cognitive impairments in a manner that meets the patient’s needs.

Fulfill three requirements at once – providing means of communication for patients protected under the Americans with Disabilities Act and Section 1557 of the ACA.

Step 3: Prepare the staff

Staff qualifications and access training

If you decide to utilize trained bilingual staff for interpretation, make sure you follow the standard regarding defining and verifying their qualifications.

STANDARD

HR.01.01.01
The hospital defines and verifies staff qualifications.

EP 1. The hospital defines staff qualifications specific to their job responsibilities.

Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964.

Bilingual staff, dedicated in-house interpreters, and in-house translators

If your staff is comfortable either communicating with their patients in their second language or working as an interpreter for other providers on an as-needed basis, make sure to assess their proficiency and then include this role in their official job descriptions. If you cannot assess language proficiency in-house, many external vendors can perform language proficiency assessments for you.

When hiring in-house language interpreters and translators, qualifications can consist of a language proficiency assessment, education, training, or experience. For sign language interpreters, consider requiring Registry of Interpreters for the Deaf (RID) certifications or an equivalent.

Fulfill two requirements at once – Section 1557 of the ACA also requires bilingual staff to have interpreting listed as part of their job description and be “qualified.”

Training other staff to use language services

Staff should feel comfortable accessing language services and working with interpreters.
Training should include:

how to request translations for their department (note that some vendors use translation memory that can be applied across multiple departments and facilities for reduced costs)
which languages are in-house versus when to call a remote interpreter
how to call a remote interpreter and troubleshoot connectivity issues
if your hospital has a policy regarding specific situations when choosing interpretation modality (for example, a diagnosis, post-op, or discharge may call for different responses)
how to put in a request for an on-site or staff interpreter
the laws and consequences regarding the use of unqualified individuals, including a patient’s family members or friends, to provide language services
how to collect preferred-language information and include it in a patient’s medical record

We recommend making an eLearning training module or other official training documentation to present to the Joint Commission if they request it.

Step 4: Collect Data

Records and patient data collection

Keeping records and data not only keeps you compliant with Joint Commission standards, it helps your organization better assess patient needs.

STANDARD

RC.02.01.01 The medical record contains information that reflects the patient’s care, treatment, and services.

EP 1. The medical record contains the following demographic information:

The patient’s name, address, date of birth, and the name of any legally authorized representative
The patient’s sex
The legal status of any patient receiving behavioral health care services
The patient’s communication needs, including preferred language for discussing health care

EP 25. The medical record contains the patient’s race and ethnicity.

How to collect patient language information

If your hospital doesn’t currently address language preference, add new fill-in spaces, fields, or drop-down menus to initial admission patient forms to capture language data. The American Hospital Association Institute for Diversity and Health Equity (AHA IFDHE) has an excellent online resource, the Health Research and Educational Trust Disparities Toolkit, which goes into the details of collecting data.

Things to keep in mind

How else language and patient data may be helpful for your organization

You can also create a process to help your staff identify patients with unique needs faster. For example:

color-coding the patient’s chart
adding flags or stickers to the patient’s chart
using patient armbands to denote different patient needs

Collecting patient language information may help you refine your results from Step 1. It could give you a clearer picture of your patient population, which your facility could use to develop or modify services, programs, or initiatives.

Step 5: Inform

Informing the patient of their rights

Maintain transparency and demonstrate that your organization respects your patients’ right to communication.

STANDARD

RI.01.01.01
The hospital respects, protects and promotes patient rights.

EP 1. The hospital has written policies on patient rights.

EP 2. The hospital informs the patient of the patient’s rights.

EP 5. The hospital respects the patient’s right to and need for effective communication.

EP 6. The hospital respects the patient’s cultural and personal values, beliefs, and preferences.

EP 9. The hospital accommodates the patient’s right to religious and other spiritual services.

EP 29. The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

Patient rights you should know

Several patient rights address the unique needs of individuals, such as the right to:

a language interpreter
accommodation for a disability
freedom from discrimination when receiving care
a support person during their hospital stay
a surrogate decision-maker

Fulfill two requirements at once – Section 1557 of the ACA also requires notices of nondiscrimination and taglines to be posted.

Ways to inform patients of their rights:

Post relevant hospital policies (in the most frequently encountered languages) in the waiting room.

Include information about relevant hospital policies in patient rights documents.

Provide patient rights materials in multiple languages and alternative formats (for example, audio, visual, or written materials).

Explain the right to have a language interpreter, the role of the interpreter in the health care encounter, and that it is a free service provided for the safety of the patient.

Step 6: Provide Care

Putting it all together to provide care to LEP patients

From in-take to discharge, using language services helps you confirm patient consent and avoid miscommunication throughout your patients’ stays.

STANDARD

PC.02.01.21
The hospital effectively communicates with patients when providing care, treatment, and services.

EP 2. The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient’s oral and written communication needs.

Make it easy for staff to provide language services

When the staff reviews the patient’s medical record, they can determine their preferred language and arrange for any sensory or communication needs. Collecting initial admission information can also help staff coordinate communication assistance, plan for cultural, religious, or spiritual accommodations, or provide necessary equipment throughout the care continuum.

STANDARD

RI.01.03.01
The hospital honors the patient’s right to give or withhold informed consent.

EP 13. Informed consent is obtained in accordance with the hospital’s policy and processes and, except in emergencies, prior to surgery.

Providing consent in a patients’ preferred language

The informed consent process establishes a mutual understanding between patients and providers about the care, treatment, and services the patient will receive. For LEP patients, use translated informed consent materials in the patient’s language whenever possible. Even if your hospital provides translated materials, an interpreter during informed consent discussions can help facilitate thorough and transparent communication.

Staff should note the receipt of informed consent and any communication assistance used to obtain it in the medical record.

Have more questions?

For educational and informational purposes only. Not intended for legal use.

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How language services benefit customers and contact centers

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Video subtitles: why you need professional translation

Joint Commission standards
for language access

How to create a Joint-Commission-compliant language access program

Step 1: Research

What does your patient population look like?