Letter to UCSF on Behalf of Limited English Proficient Patients

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Dear UCSF Chancellors, Deans, & Administrators,

We are fortunate to work in a world-renowned health and healing center, where leadership responds to national events in such a timely and germane manner with this statement:

“As leaders of this institution, we are committed, morally, strategically, and financially to ensure that UCSF leads the way in achieving a culture where differences are celebrated as essential to our strength; where equity is prized as a core value; where inclusion is viewed as the enduring quality of our communities.”

Unfortunately, systematic and ubiquitous occurrences of exclusion have not been adequately addressed, despite repeated documentation and presentation of such to administrators, at many levels, over many years.

We are writing to ask that as our leadership you act in both word and deed to support that moral, strategic and financial commitment by instituting four small, simple and concrete actions that will make a significant impact towards respect, diversity and real inclusion. These changes are straightforward, and are medically, legally and ethically responsible. As we grapple with acts of hate, discrimination and exclusion, only structural solutions will effectively address the void in structural competencies to support diversity, inclusion and health equity.

1. Post Signage: Welcome and Access to Language Services in All Threshold Languages

We must welcome all who come through our doors, including our threshold Limited-English Proficient (LEP) patients. A welcome is only meaningful in a language that is understood, and only if visible. Federally mandated signs that advise patients of their rights to receive care in a language they can understand are not regularly posted as guidelines delineate — at all major points of contact (entrances and information desks, registration, waiting rooms). There is almost nothing at entrances. “Communication is key” signs designed according to UCSF graphic and messaging specifications have been produced yet remain mostly un-posted. These signs also lack any message for American Sign Language (ASL) users. In many key patient-contact places where signs should be permanently posted, language access signs have been refused, prohibited or removed. This contrasts with the abundant, redundant signage to remind the public of our excellent reputation, our tobacco-free policy, spaghetti dinners, how much we care or elevator construction. As a community, we need to prioritize outgoing messages. Please direct your active, vocal support to posting of required signage with the imperative structures for responsible oversight and accountability. A directive from the top is essential. The lack of signage can be remedied quickly, promote compliance with federal guidelines, and support diversity and inclusion, in word and in deed.

2. Vital Documents Availability: Systematically Translate, Stock and Regularly Offer Vital Documents in All Threshold Languages

Vital forms in threshold languages are not all available, and are not offered routinely to LEPs at UCSF, in comparison to their English-speaking counterparts. For three of the last six years since we have regularly notified administrators of these lapses, we have seen some plans “in progress”. However, the simple reality remains: vital forms are still unavailable to LEP patients on a regular basis, against federal and state regulation and sensible medical and ethical practice. This is a systematic occurrence that takes place tens of times a day, hundreds if not thousands of times a year. As a community of responsible health and medical providers with the best of intentions, we are remiss. With your prioritization, this can be remedied simply, systematically and quickly. Short term compliance can happen immediately, until more permanent structural competencies are in place that supports diversity and inclusion, in word and in deed.

3. Quality Control of Language Services: Minimum National Standards of Competency and Certification (Certification Commission for Healthcare Interpreters, National Board of Certification for Medical Interpreters)

National Certification for Medical Interpreters has been available since 2010. Currently, less than 50% of Medical Interpreter staff possesses national certification. Even fewer, between 9% and 50%, in-person, contracted agency interpreters are nationally certified, though required of new UCSF staff interpreters. Reliable data on national certification for remote telephone and video interpreters are not available or is non-existent: All Spanish language video interpreting at UCSF is being performed by interpreters though contractor agencies in five countries outside the U.S. (outsourced, off-shored). Currently, neither the contractors nor UCSF require U.S. national certifications of these contracted interpreters; national certification requirements were omitted from contracts despite previous agreement and tens of millions of dollars in contracts yearly. Patients and providers at UCSF complain of unreliable levels of competence among interpreters. Inaccuracy, omission, lack of medical vocabulary and incomprehensible varieties of Spanish as well as the need to repeat medical encounters with alternative interpreters — or in summary, poor quality communication — lead to miscommunication of health plans, reduced levels of patient adherence, repeat admissions and additional expenses born by the medical center and a vulnerable patient population.

The absence of minimum, common measures of competency among interpreters at UCSF may jeopardize and, at the very least, make it difficult to guarantee that the care provided to our LEP patients is equitable to the care provided to their English-speaking counterparts, or that reasonable efforts have been made to do so. This is a structural, institutional disparity in the provision of health services. A minimum requirement of national certification of interpreters at UCSF and from remote locations can begin to address this inequity. With your active support and direction for implementation, oversight and accountability, this can be remedied to promote compliance and support diversity and inclusion, in word and in deed.

4. Meaningful Discharge and Pharmacy Instructions in Comprehensible Language of Preference

Every day on UCSF campuses, patients are discharged from in-patient and out-patient units with care plans. These involve life-threatening and life-saving instructions and complicated drug regimens. While provision of these instructions in writing is provided to our English-speaking patients, they are not provided for our LEP patients in their indicated language of preference, contributing to higher health risks and diminished health outcomes. Despite the many available, existing remedies for providing written discharge and pharmacy instructions to patients in their language of preference for healthcare, they are not provided to LEP patients. This is dangerous. It results in a clearly discriminatory practice of health care provision based on patients’ national origin (language), and ultimately excludes or limits health access for LEPs. This situation has been brought to the attention of various administrators for many years, but continues to impact scores of patients every day. This calls for an immediate, structural and institutional remedy. With your active prioritization and specific direction for implementation, oversight and accountability, this can be remedied in short order, promoting compliance with federal requirements and truly supporting diversity and inclusion, in word and in deed.

While we cannot speak to the many reasons why these well-documented violations have persisted, current paradigms to address them are incomplete, ineffective or absent. They do not sufficiently address structural inequities nor do they meet the needs of UCSF’s patients. At the same time, many of us with language access expertise on the front lines would be pleased to collaborate on successful efforts toward inclusion and respect for all the UCSF community of health professionals and patients. We are available through the Do No Harm Coalition.

The UCSF messages of pride in our intentions and accomplishments often declare that we are outstanding, that we are unique, that we provide care superior to many, and that we are among the 10 Best. If we truly believe this, let us step up and be accountable for that reputation. Let us take seriously the provision of equitable care for all, by standing, acting and modeling diversity, respect and inclusion of all our patients.

Thank you for considering immediate actions to address health provision inequities and stand behind the recognition of our diversity and for the inclusion of all, in word and in deed.

Do No Harm Coalition

admin@donoharmcoalition.org

Fabian Fernandez, MD/PhD Candiate 2024 UCSF

Anita Hargrave, MD Candidate 2017 UCSF

Rupa Marya, MD, Assistant Professor Division of Hospital Medicine UCSF, Do No Harm Coalition Faculty Director

Lisa Hartmayer, RN, NP UCSF

Morgan L Weinert, RN, MSN Candidate 2018 UCSF

Max Feinstein, MD Candidate 2020 UCSF

Denisse Porter, Nursing Student UCSF

Deborah Cohan, MD, MOH UCSF

Jennifer Sneden, MD Candidate 2017 UCSF

Elaine Hsiang, MD Candidate 2020 UCSF

Chris Ahlbach, MD Candidate 2020 UCSF

Sam Kadin, MEPN Student UCSF

Erin Anderson

Simon Ma, MD Candidate 2020 UCSF

Aviva Milner-Brage, UAW Local 5810

Rachel Fields, MD Candidate JMP

Cicily Cooper, FNP Student UCSF

Alma Celia Sánchez, MD UCSF Family and Community Medicine

Melissa Ramirez-Medina, MSN UCSF

María Ramos Bracamontes, RN, SNM CNM/WHNP UCSF

Mike Sweeney, RN, FNP Student UCSF

Briton Lee, MD Candidate 2020 UCSF

Amanda K. Johnson MD, MBA UCSF Internal Medicine Residency

Lauren Trainor, CNM, MS UCSF

Danny Kim, MD Candidate UCSF

Robert Lustig, MD UCSF

Anita Verma, MD Candidate 2017 UCSF

Wendi Felson, Clinical Laboratory Scientist, Ret.UPTE-CWA 9119

Barbara Handler

Julieta Kusnir, MPH City College of San Francisco

Andrea Zengion, RN, MS Candidate 2017 UCSF

Leila Ben, MD Alameda Health

Liz Kroboth, MPH San Francisco State University

Peggy O’Grady, LCSW UCSF Benioff Children’s Hospital

Cynthia Fong, Housing Rights Committee of San Francisco

Jill R. Tregor, MPH

Nicole Sata, CNM, WHNP

Diana Rosa, Mayo Patient

Juliet Huntington, CNM San Francisco General Hospital

Erin Kinmont, Nursing Student UCSF

Ezekiel Adigun, MD Candidate 2020 UCSF

Matthew Sachs, RN Candidate UCSF

Teresa Palmer, M.D. Family Doctor Private Practice

Bianka Aguilar, MD Candidate 2021 UC Berkeley

Erika Smith

Kelly Knight, PhDUCSF — School of Medicine

Holly Cost, CNM MS, Associate Clinical Professor, Ob/Gyn and RSSFGH/UCSF

Anjali Asrani, MEPN Candidate UCSF

Kelly Earls, LCSW, MPH UCSF Benioff Children’s Hospital

Yuyang Mei, MD Candidate 2017 UCSF

Ammar Joudeh, MD Candidate 2020 UCSF

Wes Falatoonzadeh, Nurse Manager, RNUCSF, Clinical Research Services

Nino Maida, UCSF SRA-3 (Ret)UPTE-CWA 9119

Sara I., LCSW UCSF

Sonia Milbank, MSW UCSF

Amanda Bloom, PA-C

Cindy Hong, MPH Candidate SFSU

Brenna Taylor-Ford, MSW PICU UCSF Benioff Children’s Hospital

Shahed Mofidi, UCSF Medical Center

Lisa Moore, Dr PH San Francisco State University

Kaylan Agnew, MSc.UCSF Division of Medicine

Elizabeth Milos, UCSF Medical Interpreter and member of UPTE-CWA Local. 9119

Amie Rudolph, LCSW Clinical Social Worker UCSF Benioff Children’s Hospital

Yogi Hendlin, Postdoctoral Research Fellow UCSF

Ilana Garcia-Grossman, MD Candidate 2017 UCSF

Lily Barnard, MD Candidate 2020 UCSF

Malka Scheinok, Patient at UCSF

Josephine Valenzuela, MD UCSF GH

Cristy Dieterich, MPH

Elaine Khoong, MD UCSF

Angelica Cardenas, Health Educator SFDPH

Margaret Stafford, Faculty at UCSF SOM

Aileen XuRN, Candidate 2017, FNP Candidate 2019 UCSF

Katy Spence, LMFT Alternative Family Services

Jimmy Goh, School of Nursing UCSF

Ariana Thompson Lastad, PhD candidate, Sociology UCSF

Vanessa Mercado, Program Coordinator UCSF

Galina Yudovich, MPH San Francisco State University

Rachel Yanda, RN UCSF

Michalle Ramirez-McLaughlin, FNP-BCUCSF

Tia Cole, CNM student UCSF

Eric Smith,MD Candidate 2022 UCSF

Desiree Dieste, LCSW MPH, UCSF Benioff Children’s Hospital

Kate Emerson, CNM WHNP-BC

Florence H. Chien, MPP MEPN, Nursing Student UCSF

Cameron Donald, MD Candidate 2020 UCSF

Johann Frazier, City of Richmond — Community Services

Stephannie Leong Ratcliff, MD Candidate 2021, UCB-UCSF Joint Medical Program

Lisa Thompson, RN FNP PhD, UCSF

Alina Kung, MD Candidate 2019, UCSF School of Medicine

Jill Watt, BSN RN MSN Candidate 2017, UCSF School of Nursing

Sara Minahan, RN & CNM student, UCSF School of Nursing Midwifery Program

Melanie Staehelin, CNM WHNP Candidate 2017, UCSF

Johanna Glaser, MD Candidate 2019, UCSF

Regan Watson, Student-Nurse, SON

Kate Berry-Millett, Nursing Student, UCSF

Sylvia Stoffella, PharmD, UCSF

Kate Murphy, UCSF

Freya Magnusson, HUSC III, UCSF Benioff Children’s Hospital

Alison Davis, MEPN student, UCSF

Loraine Woodard, Oakland International High School

Camille Rogine, MD Candidate 2020, UCSF

Suzanna Reiss-Koncar, MPH, UCSF

Anga Lao, AuD, UCSF

Xin-Hua Chen, LCSW, Clinical Social Worker, UCSF Benioff Children’s Hospital San Francisco

Desiree Dieste, LCSW MPH, UCSF Benioff Children’s Hospital

Molly Koren, LCSW, UCSF Benioff Children’s Hospital

Jessica Peck, MSW, UCSF

Jessica Manning, LCSW, UCSF

Margarita Antonetti, Medical Interpreter II, UCSF

Suzanna Reiss-Koncar, MPH, UCSF

Caroline Hill, Clinical Social Worker, UCSF Benioff Children’s Hospital

Emmy Yang, MD Candidate 2020, Icahn School of Medicine

Anya Dubin, Clinical Social Worker, UCSF

Joseph Osorio, MD PhD, UCSF

Adi Afek, RN CNM/WHNP Candidate 2018, UCSF

Meg D. Newman, MD, UCSF

Sofia Noori, MD Candidate 2017, UCSF

Teresa Scherzer, PhD MSW, UCSF

Omar Mesina, MD Candidate 2020, UCSF

Michelle Hermiston, MD/PHD Pediatric Hematology-Oncology, UCSF

Nikko Gonzales, MD Candidate, UCSF

Sabine Mueller, MD, UCSF

Pamela Gudino, RN MPH FNP Student, UCSF

Tanya, CRC, UCSF

Varsha Shenoy, CRC, UCSF

Jeremy, MD Candidate 2020, UCSF

Jillian Foley, LCSW, UCSF Benioff Children’s Hospital

Michael Deng, MD Candidate 2020, UCSF

W. Clay Gustafson, MD/PhD, UCSF

Jeffrey Edwards, MD Candidate 2020, Stanford University

Jose Lopez, MD candidate 2020, UCSF

Maryam Shansab, PhD, UCSF

Pegi Walker, Chaplain

Silvio Menendez, Medical Interpreter II, UCSF

Kelley Boyle, MSN, UCSF

Carly Hoffman, PNP, UCSF

Haley Davies, MEPN Candidate, UCSF

Sikai Song, MD Candidate 2020, UCSF School of Medicine

Nathan Kim, MD Candidate 2020, UCSF

Anna Garzon, Clinical Research Coordinator, UCSF

Carolina Ornelas, MD Candidate 2020, UCSF

Julio Gonzalez Maya, MD Candidate 2021, UCSF

Angela Broad White, MD Candidate 2017, UCSF

Cassie Kline, MD, UCSF Benioff Children’s Hospital

Maggie Root, PNP, UCSF Benioff Children’s Hospital

Max Feinstein, MD Candidate 2020, UCSF

Freya Magnusson, HUSC III, UCSF Benioff CH

Emilia De Marchis, MD, UCSF

Ana Delgado, CNM, ZSFG Dept of OBGYN

Sarah Eisenstein, B.S.N. Candidate 2017, University of Maryland School of Nursing

Kenji Taylor, MD, UCSF FCM Resident

Jackie Barshak, San Franciscans for Police Accountability

Michael B. Adams, Former Director, UCSF Affirmative Action/Equal Opportunity/Diversity

Gabrielle Westergren, CNM, SFDPH/ZSFGH

Anita Skidmore, Administrative Assistant, UCSF

Shelley Nunez-Guzman, Academic Assistant & Patient, UCSF

Amber Bell, RN, UCSF

Claire Parker, NP, UCSF

Andrea Pfeffer, CNM, SFGH

Ruth Maltez, Surgical Coordinator, UCSF

Sila M. Alvarenga, HR Business Partner, UC Berkeley

Youngwoon Huh, Surgery Coordinator, DO Candidate 2021, UCSF

Crystal Diaz, Admin Analyst, UCSF Medical Center

Brenda Gonzalez, Hospital Assistant III, UCSF Benioff Childrens Hospital

Carolina Garcia, Employee, UCSF

Rosalie Andino, Patient Care Liaison, UCSF

Celia Garcia, Hospital Assisitant, UCSF

Sarah Benckart, Nursing Student, UCSF

Jill Warren

Natalie King

Monica Diaz, Admin, UCSF

Deborah Anderson, CNM, UCSF

Cate Flanagan, RN, FNP(c), UCSF

Monica Jarman, UCSF Benioff Children’s Hospital

Mariel de la Paz, MSW

Jacqueline Smay, Academic Analyst, Ped CT Surgery, UCSF Benioff Children’s Hospital

Ana-Maria Guerrero, UCSF

Rachel Schenkel, MD Candidate 2020, UCSF

Leanne Non, HUSC, UCSF

Cliff O’Neill, UPTE/CWA

Xochitl Castaneda, Director, Health Initiaitive of the Americas

Sophia Zepeda

Julie Keiko Beal, MSW Intern, UCSF Benioff Children’s Hospital

Teresa Gomez-Bramble, MD, UCSF Family and Community Medicine

Kara Myers, CNM, Associate Clinical Professor, UCSF

Juliana Morris, MD EdM, UCSF

Margaret Hutchison, CNM, Zuckerberg San Francisco General

Michele Perlmutter, CHI Medical Interpreter, UCSF

Matthew Palmquist, University of California Berkeley

Jenny Check, RN, UCSF

E. Alejandro Sweet-Cordero, MD, UCSF

Ivette Gomez, Research Analyst, UCSF Benioff Childrens Hospital

Mignon Loh, Professor of Pediatrics, UCSF

Stephanie Petruzzi, MSW, UCSF

Raquel Oropeza, Practice Coordinator III — Pediatric Cardiology, UCSF Medical Center

Ashley Koegel, MD, UCSF

Nicholas Murphy, MD Candidate 2019, UCSF SOM

Jenee Areeckal, MSW, LCSW, UCSF Benioff Childrens Hospital

Scott Steiger, MD Associate Professor of Medicine and Psychiatry, UCSF

Trish Murphy, RN, UCSF

Adam Numis, MD, UCSF Neurology,

Maria Roberta Cilio, MD PhD, UCSF

Joseph Sullivan, MD, UCSF

Elsa Casillas, Patient Care Coordinator, UCSF

Geraldine Dalida, Clinic Practice Assistant, UCSF Pediatric Brain Center

Jennifer Graves, MD PhD MAS, UCSF

Rowena Mah, RN MS, UCSF

Erica W., Practice Coordinator, UCSF Benioff Children’s Hospital Pediatric Brain Center

Christina O’Shaughnessy, Administrative Analyst I, UCSF

Audrey Malaer, RN

Raquel Guillen, UCSF

Geraldine Mallari, Practice Coordinator III, Pediatric Brain Center

Adali Martinez MD Candidate 2018, UC San Francisco

Kristin Adkins, RN UCSF Medical Center

Marcela Cordova, Practice Assistant UCSF Pediatric Brain Center

Nancy Iriarte-Reyes, Practice Coordinator UCSF

Nancy Matthiessen, Registered Dietitian UCSF Medical Center

Wendy Chambers, Hospital Assistant UCSF Benioff Children’s Hospital

Daniela Maristany, MD Candidate 2017 UCSF

Megan Murphy, RD UCSF

Tara Valcarcel, CPNP UCSF Benioff Children’s Hospital

Yvette Wild, MD/ MPH UCSF

Diane Wara, MD Professor emeritus, Dept of Pediatrics, UCSF

Zoe Julian, MD/ MPH UCSF OBGyn Residency Program

Aisha Ahmed, MD

Alice Chan, MD/PhD UCSF

Theodore Ruel, MD UCSF

Anna K Meyer, MD UCSF Otolaryngology

Stephany Pizano, Program Coordinator Health Initiative of the America, School of Public Health, UC Berkeley

Sarah Schaeffer, MD/ MPH UCSF

Silvia Bellfort-Salinas, MSW UCSF Benioff Children’s Hospital

Christina T. Badasow, RN UCSF Children’s Hospital Mission Bay

Besim Uzgil, MD/ PhD UCSF

Elana Curry, LCSW UCSF Benioff Children’s Hospital

LaMisha Hill, PhD Director, Multicultural Resource Center, Diversity and Outreach

Michael Lyon, MA Gray Panthers of SF

Madhavi Dandu, MD UCSF

Lauren Sanchez, MD UCSF

Megan Gaydos, MPH Independent Public Health Consultant

Abigail Gutmann-Gonzalez, Resracher and Evaluator UCSF

Lissette Irizarry, UCSF

Chrissy Friesen, UCSF

Amber Akemi Piatt, MPH

Carla Francisco

Teddy Miller, J.D. New Leaders Council

Mary J. Potts, Physical Therapist UCSF Mission Bay Campus

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