EO 13166, Improving Access to Services for Persons with Limited English Proficiency, requires that all federal agencies take reasonable steps to ensure meaningful access to their programs and services for people with LEP. DOJ has issued guidance that spells out four factors agencies need to consider in determining whether they are taking reasonable steps in this regard: (1) the number or proportion of LEP persons in the eligible service population; (2) the frequency with which LEP individuals come in contact with the program; (3) the importance of the services provided by the program; and (4) the resources available. Reasonable steps to ensure meaningful access could include developing language access services and guidance for implementing these services. The EO required that each federal agency create a plan outlining steps it will take consistent with DOJ guidance to ensure meaningful access to its services by LEP individuals. The EO did not require DOJ to evaluate the plans or to monitor the implementation of these plans. In 2002, in response to EO 13166, VA created and implemented VHA Directive 2002-006. It provided a framework for VA medical centers to assess and determine if there was a need to develop language assistance policies and language access services. The medical centers retain flexibility to determine exactly how they will comply with the EO, but they must do so in accordance with the four factors as outlined by DOJ and reiterated in the LEP Directive. In February 2007, VA issued VHA Directive 2007-009, which renewed VA’s guidance on language assistance policies. In its LEP Directive, VA outlined the steps that constitute an effective language assistance program at its medical centers, including an assessment of the language needs of the veteran population served and identification of the non-English languages encountered by medical center staff. If a VA medical center identifies a specific language need among its veteran service population, VA’s LEP Directive also indicated that the medical center should develop and implement a language assistance policy to ensure meaningful communication. According to the directive, the policy should describe how the medical center plans to provide language access services and ensure that all veterans receive meaningful access to VA health care services, regardless of the veterans’ level of English proficiency. VA’s LEP Directive also provided medical centers with examples of ways to provide language access services—including, translating written materials, hiring bilingual staff, and contracting with interpreter services. VA’s Equal Employment Opportunity (EEO) office is responsible for overseeing the implementation of VA’s LEP Directive. As such, this office conducted surveys of VA medical centers to assess whether medical center officials were following the steps outlined in the LEP Directive, such as conducting an assessment of language needs, or otherwise taking reasonable steps to provide language access services for veterans being served. VA’s Center for Minority Veterans (CMV) is also involved in helping medical centers meet the language and cultural needs of the veteran population. CMV is responsible for ensuring that eligible minority veterans receive VA benefits and services. Culturally appropriate health care is care that is respectful of and responsive to the cultural needs of patients. According to HHS, providing culturally appropriate services to culturally diverse patients has the potential to improve access to care, quality of care, and ultimately, health outcomes. HHS has published a set of standards for all medical facilities regarding the delivery of culturally appropriate care. Other national organizations also recognize the importance of culturally appropriate care and have established standards or recommendations for its provision. For example, the Joint Commission has standards related to culturally appropriate health care that must be met by hospitals, including VA medical centers, to receive accreditation. VA medical centers are implementing VA’s LEP Directive in terms of assessing the language needs of its veteran service population, and, if necessary, developing language assistance policies. VA medical centers and facilities have offered language access services that include providing translated materials and interpretation services to meet the needs of veterans with LEP. VA medical center officials reported a low utilization of these language access services. However, VA and medical center officials told us that they expect the demand for language access services to grow as the increasingly diverse servicemember population transitions to veteran status. VA stated that by June 2007 all of its medical centers had taken actions to implement the guidance in VA’s LEP Directive. According to VA, all of its medical centers have assessed the language needs of its veteran service population, and, as necessary, developed language assistance policies. Our visits to three VA medical centers and in-depth telephone interviews with staff at three VA medical centers provided a more detailed account of the variety of language access services being offered at VA medical centers. VA first surveyed each of VA’s medical center directors in December 2005 to assess if medical centers were following the guidance in VA’s LEP Directive. The survey contained 10 “yes” or “no” questions to gauge the extent of medical centers’ efforts to implement the LEP Directive. The questions ranged from issues such as overall language assistance policies to efforts to provide language access services. If a “no” response was provided for any question, the medical center directors completing the survey were instructed to indicate a tentative date by which they would take action to address the item. VA required medical center directors and VISN directors to ensure that the responses for individual medical centers were completed. However, VA did not require that VISN or medical center directors provide documentation to support their “yes” responses to the survey. The results of the 2005 survey showed that 65 percent of VA medical centers had assessed the language needs of their veteran service population and that 60 percent of the centers had developed a language assistance policy. While completing the survey, VA medical center directors reported information about other medical center efforts to meet the needs of LEP veterans, including efforts to translate documents and hire bilingual interpreters. For example, 87 percent of VA medical center directors reported establishing a list of staff available for interpretation services and that 24 percent of VA medical centers had translated written documents into languages other than English. After conducting its initial survey, VA took several steps to help medical centers improve their efforts to implement the LEP Directive, according to a VA official. VA staff made follow-up calls to VA officials from the medical centers that did not respond to the survey or that were identified by the survey as not conducting efforts consistent with the LEP Directive. During these follow-up efforts, VA staff offered guidance to medical center officials on conducting language needs assessments and developing language assistance policies in ways that were consistent with the LEP Directive. According to officials we interviewed at two VA medical centers, the guidance was helpful in their facilities’ assessment of language needs among their service population and development of language assistance policies. According to VA, the follow-up efforts proved successful, as all medical centers reported that they had assessed the language needs of their veteran service population, and, as necessary, developed language assistance policies. In July 2007, VA reported that as a result of its follow- up efforts, all of VA’s medical centers, in accordance with the LEP Directive, had assessed the language needs of their veteran service population and developed language assistance policies as needed. VA concluded that because of the progress and efforts made by its medical centers to implement the LEP Directive, VA would not conduct any additional evaluations of medical center implementation of the LEP Directive. Instead, VA said it would rely on the medical centers to monitor their own LEP language access needs and programs. VA medical centers and other VA facilities have access to a variety of translation services. At the national level, VA has translated its widely distributed benefits publication into Spanish and makes information from this publication available in Spanish on its Web site. All VA medical centers have computer software that offers medical treatment consent forms in Spanish and additional software that allows VA staff to access patient education materials in several languages other than English, such as Spanish and Korean. The VA medical centers and facilities included in our in-depth review also provide translated materials to meet the various language needs of their veteran service populations. We found that all six medical centers in our in-depth review translate written materials on their own. For example, staff at one medical center we interviewed told us that they translated educational materials on traumatic brain injuries into Spanish. However, staff at the medical centers reported that they primarily rely on publicly available translated documents rather than translating written materials on their own because of the cost of independently translating documents. The sources of these publicly available materials range from other federal agencies to results of an Internet search. For example, according to VA officials, patient educators at some medical centers use patient education materials on a range of topics including heart disease and diabetes that have been translated into Spanish by HHS’s Food and Drug Administration. VA medical center staff can also use materials translated by staff at other medical centers. For example, staff at one medical facility we reviewed reported that the VA medical center located in San Juan, Puerto Rico, has shared patient education materials they have translated into Spanish with other VA medical centers. Medical center staff we interviewed also reported using professional groups within VA, such as EEO managers or patient educators, to identify and share existing translated materials. However, these groups are limited in their membership and, as such, might not be aware of all translated materials available at VA medical centers. Additionally, VA medical facilities included in our review generally offer translated materials specific to the services they provide, when needed. For example, one Vet Center we reviewed translated a pamphlet on post-traumatic stress disorder into Spanish for its largely Hispanic veteran service population. As part of language access services, VA medical centers we reviewed in depth provide language interpretation services to help address the language needs of veterans with LEP. Staff we interviewed at all six medical centers we reviewed had the ability to provide interpretation services to veterans with LEP and were doing so in several different ways.