SETTLEMENT AGREEMENT BETWEEN THE UNITED STATES OF AMERICA AND SWEDISH MEDICAL CENTER FIRST HILL
USAO #2018V00423; DJ #202-82-153

1. Background
   1. The parties (“Parties”) to this Settlement Agreement (“Agreement”) are the United States of America (“United States”) and Swedish Medical Center First Hill (“Swedish First Hill” or “the Hospital”).
   2. Swedish First Hill is a hospital that provides inpatient and outpatient treatment programs, located at 747 Broadway, Seattle, WA 98122.  Swedish First Hill’s services include emergency services and surgery.  Swedish First Hill is among the facilities within the healthcare network commonly referred to as Swedish.
   3. This matter was initiated by the U.S. Attorney’s Office for the Western District of Washington (“U.S. Attorney’s Office”), a component of the Department of Justice, after receiving complaints in 2018 from an individual who is deaf and another who is deaf-blind alleging that Swedish First Hill violated Title III of the American’s with Disabilities Act of 1990 (“ADA”) by failing to provide them effective communication, including sign language or tactile interpreters during medical appointments or care, surgical consultations, surgery, and/or pre- and post-operative surgical portions of the patient ’s medical care. The U.S. Attorney’s Office received an additional complaint in 2019 from another individual who is deaf-blind alleging that Swedish First Hill violated Title III of the ADA by failing to provide effective communication during an emergency room visit and discharge from the hospital.
2. INVESTIGATION AND DETERMINATIONS
4. The U.S. Attorney’s Office is authorized to investigate alleged violations of Title III of the ADA.  42 U.S.C. § 12188(b)(1)(A); 28 C.F.R. § 36.502.  It also has the authority to, where appropriate, negotiate voluntary settlements, and to bring civil actions enforcing Title III of the ADA should the terms of the settlement be breached.  42 U.S.C. § 12188(b)(1)(B); 28 C.F.R. § 36.503.
5.  Complainants D.A. and B.V. are deaf-blind, and Complainant J.A. is deaf. All three complainants are individuals with a “disability” within the meaning of the ADA. 42 U.S.C. § 12102; 28 C.F.R. § 36.104.
6. Swedish First Hill is a “public accommodation” within the meaning of Title III of the ADA, 42 U.S.C. § 12181(7)(F) and its implementing regulations, 28 C.F.R. § 36.104, as it is a hospital and professional office of health care providers.  The ADA prohibits public accommodations, including hospitals, from discriminating on the basis of disability in the full and equal enjoyment of their goods, services, facilities, privileges, advantages or accommodations.  42 U.S.C. § 12182(a); 28 C.F.R. § 36.201(a).  Discrimination includes failing to take such steps as necessary to ensure that no individual with a disability is excluded, denied services, segregated, or otherwise treated differently than any other individual because of the absence of auxiliary aids and services.  42 U.S.C. § 12182(b)(2)(A)(iii); 28 C.F.R. § 36.303.
7. Swedish First Hill fully cooperated with the United States’ investigation in this matter.  In the course of the investigation, the United States determined that Swedish First Hill failed to provide D.A. with a qualified tactile interpreter necessary to effective communication on several occasions in 2018, including pre-surgical consultation, surgery, and post-surgical care.  The United States determined D.A. suffered emotional distress from the experience.  The United States further determined that Swedish First Hill put D.A.’s brother in a position where he felt obligated to provide interpretation services for D.A., which was improper and placed D.A.’s brother in the difficult position of serving as both a supportive companion and medical interpreter, a position for which he is not qualified.  In the course of investigation, the United States also determined that Swedish First Hill failed to provide J.A. with a qualified American Sign Language (“ASL”) interpreter necessary to effective communication during her post-surgical consultation/discharge meeting with her health care provider. Finally, the United States determined that Swedish First Hill failed to provide B.V. with a qualified tactile interpreter necessary to effective communication during his March 2019 visit to the emergency room and during his discharge from the hospital.
8. On the basis of these determinations, the U.S. Attorney’s Office concluded that Swedish First Hill denied Complainants D.A., B.V., and J.A. auxiliary aids and services necessary for effective communication in violation of 42 U.S.C. § 12182(b)(2)(A)(iii) and 28 C.F.R. § 36.303 at times during Complainants’ periods of care.  The U.S. Attorney’s Office also concluded that Swedish First Hill engaged in associational discrimination against D.A.’s brother in putting him in a position, on several occasions, to choose between serving as a medical interpreter for his brother or allowing his brother to struggle with communications with his medical providers.  See 42 U.S.C. § 12182(b)(1)(E).
3. DEFINITIONS
9. The term “Auxiliary Aids and Services” includes qualified interpreters provided either on- site or through video remote interpreting (“VRI ”) services; note takers; real-time computer- aided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunications products and systems, including text telephones, videophones, and captioned telephones, or equally effective telecommunications devices; videotext displays; accessible electronic and information technology; or other effective methods of making aurally delivered information available to individuals who are deaf, deaf-blind, or hard-of-hearing.  28 C.F.R. § 36.303.
10. The term “Swedish First Hill Personnel” means all employees, both full time and part-time, and independent contractors with contracts to work on a substantially full-time basis for Swedish First Hill (or on a part-time basis exclusively for Swedish First Hill), including, nurses, physicians, social workers, technicians, admitting personnel, billing staff, and therapists who have or are likely to have, direct contact with Patients or Companions as defined herein.  For purposes of this Agreement, Swedish First Hill Personnel do not include third party contractors, including, but not limited to, maintenance or custodial contractors, whose job responsibilities do not involve direct interaction with Patients or Companions.
11. The term “Active Members of the Medical Staff” means all persons who are credentialed and privileged and provide medical services involving direct contact with Patients or Companions at Swedish First Hill, whether or not they are direct employees of Swedish First Hill.
12. The term “Qualified Interpreter” means an interpreter who, via VRI service or an on-site appearance, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary.  28 C.F.R. § 36.104.  Qualified Interpreters include, for example, sign language interpreters, tactile interpreters, oral transliterators, and cued-language transliterators.  For purposes of this Agreement, a Qualified Interpreter must be knowledgeable with medical terminology.
13. The term “Patient” shall be broadly construed to include any individual who is seeking access to, or participating in, the goods, services, facilities, privileges, advantages, or accommodations of Swedish First Hill, whether as an inpatient or an outpatient.
14. The term “Companion” means a person who is a family member, friend, or associate of an individual seeking access to, or participating in, the goods, services, facilities, privileges, advantages, or accommodations of Swedish First Hill, who, along with such individual, is an appropriate person with whom the public accommodation should communicate.  28 C.F.R. § 36.303(c)(1)(i).
4. EQUITABLE RELIEF
1. Prohibition of Discrimination
15. Nondiscrimination.  Swedish First Hill shall provide appropriate Auxiliary Aids and Services, including Qualified Interpreters, where such aids and services are necessary to ensure effective communication with Patients and Companions who are deaf, deaf-blind, or hard of hearing.  Pursuant to 42 U.S.C. § 12182(a), Swedish First Hill shall also provide Patients and Companions who are deaf, deaf-blind, or hard of hearing with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of Swedish First Hill as required by this Agreement and the ADA.
16. Discrimination by Association.  Swedish First Hill shall not deny equal services, accommodations, or other opportunities to any individual because of the known relationship of that person with someone who is deaf, deaf-blind, or hard of hearing.  42 U.S.C. § 12182(b)(1)(E).
17. Retaliation and Coercion.  Swedish First Hill shall not retaliate, interfere with or coerce any person who made, or is making, a complaint according to the provisions of this Agreement or exercised, or is exercising, his or her rights under this Agreement or the ADA.  42 U.S.C. § 12203.
2. Effective Communication
18. Appropriate Auxiliary Aids and Services.  Consistent with 42 U.S.C. § 12182(b)(2)(A)(iii), Swedish First Hill will provide to Patients and Companions who are deaf, deaf-blind, or hard of hearing any appropriate Auxiliary Aids and Services necessary for effective communication after making the assessment described in Paragraph 19 of this Agreement.  Appropriate Auxiliary Aids and Services will be provided as soon as practicable (without compromising patient care), except that the provision of on-site interpreters must be within the time frame described in Paragraph 28 of this Agreement.
19. Assessment for Effective Communication. The determination of appropriate Auxiliary Aids and Services will be made by Swedish First Hill in consultation with the Patient or Companion who is deaf, deaf-blind, or hard of hearing. The determination will take into account all relevant facts and circumstances, including, for example, the individual’s communication skills and knowledge, and the nature and complexity of the communication at issue. The determination will include an assessment of the timing, duration, and frequency with which the Auxiliary Aids and Services will be needed for effective communication throughout the Patient or Companion’s visit or expected stay. The assessment will include consideration of how patient needs will be met given the reasonable possibility of delays and/or anticipated needs for flexibility based on Swedish First Hill’s typical operations.
20. Time and Method for Assessment.
1. The Assessment for Effective Communication referenced in Paragraph 19, will be made, to the extent possible, at the time an appointment is scheduled for the Patient who is deaf, deaf-blind, or hard of hearing or on the arrival of the Patient or Companion at Swedish First Hill, whichever is earlier.
2. For the Patient’s first visit to a Swedish First Hill facility after the entry of this Agreement, Swedish First Hill Personnel will perform the assessment using a Communication Assessment Form that is the same or substantially similar to Exhibit A of this Agreement. The information captured by this form will be entered into the Patient’s profile in the Swedish First Hill electronic records program (“EPIC”).
3. For all subsequent visits, Swedish First Hill will review the communication information in EPIC with the Patient and seek the Patient’s input regarding what his or her communications needs will be for the particular visit.
4. If at any time during a Patient’s visit or stay, Swedish First Hill Personnel observe or believe that the form of communication being provided is not effective or the Patient indicates it is not effective, he or she will reassess which appropriate Auxiliary Aids and Services are necessary, in consultation with the person with a disability, where possible, and provide such aid or service as soon as is practicable based on the reassessment.
21. ADA Communication Services Designee. Swedish First Hill will ensure that an ADA Communication Services Resource in which at least one designee will always be on duty and available to Swedish First Hill staff, Patients, and Companions during the same hours of operation and days of week in which Swedish First Hill is open to the public. Swedish First Hill will include in its intranet under the name “ADA Communication Services Resource” and its “Quick List” phone directory the telephone number through which the on-duty designee can be contacted by Medical Personnel. The ADA Communication Services Resource Designee(s) will be identified by Swedish First Hill no later than thirty (30) business days following Effective Date of this Agreement and notice of such identification for Swedish First Hill will be provided to the U.S. Attorney’s Office. The ADA Communications Services Resource Designee(s’)responsibilities include, but are not limited to:
1. Answering questions from staff regarding how to provide appropriate assistance to Patients and Companions who are deaf or hard of hearing, including how to obtain immediate access to, and proper use of, the appropriate Auxiliary Aids and Services;
2. Knowing where the appropriate auxiliary aids are stored and how to operate them;
3. Distributing and replacing Auxiliary Aids and Services as appropriate;
4. Maintaining Auxiliary Aids in good working order;
5. Knowing when Qualified Interpreters are necessary for effective communication and how to obtain a Qualified Interpreter for a Patient or Companion, including on an emergency or short notice basis.
22. Auxiliary Aid and Service Log.  Swedish First Hill will maintain logs in which requests for Qualified Interpreters on-site or through video remote services for Patients or Companions who are deaf, deaf-blind, or hard of hearing will be documented.  The log will indicate:
1. The name of the Patient or Companion who is deaf, deaf-blind or hard of hearing;
2. The nature of the Auxiliary Aid or Service requested;
3. The time and date the request was made by the Patient or Companion (if applicable);
4. The time and date the request was made by staff after assessing the needs of the Patient or Companion (if applicable);
5. The name of the staff member making the request;
6. The time and date the request was made for, i.e. for immediate use (emergent need) or for a scheduled appointment (stating the date and time of the appointment);
7. The time and date the request was fulfilled; and
8. The nature of the Auxiliary Aid or Service provided.
9. If the requested Auxiliary Aid or Service was not provided, was not provided in the type requested, or was provided outside of the timeliness provisions contained in Paragraph 28 of this agreement, the log shall contain a statement explaining why.

Such logs will be maintained by the ADPP at Swedish First Hill for the duration of the Agreement, and will be incorporated into the semi-annual Compliance Reports as described in Paragraph 42 of this Agreement.  Swedish First Hill will implement the Auxiliary Aid and Service Logs no later than thirty (30) days following execution of this Agreement.

23. Complaint Resolution.  Swedish First Hill will use a complaint resolution mechanism for the investigation of disputes regarding effective communication with Patients and Companions who are deaf, deaf-blind, or hard of hearing. In particular:
1. Swedish First Hill will maintain records of all complaints regarding effective communication, whether oral or written, made to Swedish First Hill and actions taken with respect thereto for the duration of this Agreement.
2. At the time Swedish First Hill completes its assessment described in Paragraph 19 and advises the Patient and/or Companion of its determination of which Auxiliary Aids and Services are appropriate, Swedish First Hill will notify persons who are deaf, deaf-blind, or hard of hearing of its complaint resolution mechanism, to whom complaints should be made, and of the right to receive a written response to the complaint.
3. A written response to any complaint filed shall be provided to the complainant as soon as is practicable, but in no event longer than thirty (30) business days after receipt of the complaint.
24. Prohibition of Surcharges.  All appropriate Auxiliary Aids and Services required by this Agreement will be provided free of charge to the Patient and/or Companion who is deaf, deaf-blind, or hard of hearing.
3. Qualified Interpreters
25. Circumstances Under Which Interpreters May be Required.  Although the determination of whether and what Auxiliary Aids and Services are appropriate to a given situation is generally to be made on a case by case basis (as informed by its assessment pursuant to Paragraph 19), some circumstances typically require that Swedish First Hill provide a Qualified Interpreter to Patients or Companions who rely upon such types of communications. Such circumstances generally arise when the communication is particularly complex or lengthy. For example, such circumstances include, but are not limited to:
1. Discussing a patient’s symptoms and medical condition, medications, and;
2. Explaining medical conditions, treatment options, tests, medications, surgery, and other procedures;
3. Providing a diagnosis or recommendation for treatment;
4. Communications immediately preceding, during, and immediately after surgery or other procedures and during physician’s rounds;
5. Obtaining informed consent for treatment;
6. Providing instructions for medications, post-treatment activities, and follow-up treatments;
7. Providing mental health services, including group or individual counseling for patients and family members;
8. Providing information about blood or organ donations;
9. Discussing powers of attorney, living wills and/or complex billing, and insurance matters; or
10. During educational presentations, such as birthing or new parent classes, nutrition and weight management programs, and CPR and first-aid training.

In such circumstances, Swedish First Hill will presume a Qualified Interpreter is necessary for effective communication with the Patient or Companion and will provide one unless otherwise directed by the Patient or Companion.

26. Chosen Method for Obtaining Interpreters. For the duration of this Agreement, Swedish First Hill will maintain relationships with at least three (3) language interpreter services that provide services including, but not limited to, sign language interpreter services and of which at least one (1) that is capable of providing interpretation to individuals who are deaf, deaf-blind, or hard of hearing during all hours of Swedish First Hill’s operation and on an emergency or short-notice (less than 24 hours’ notice) basis. If Swedish First Hill ends or alters its contracts with any of these entities or adds additional contracts during the term of this Agreement, Swedish First Hill will notify the U.S. Attorney’s Office of the change within thirty (30) days. If either Swedish First Hill or a language interpreter service terminates a contract such that the total number of contracts is less than three (3), Swedish First Hill will include a statement of why the change is not expected to impact interpreter fill rates.
27. Video Remote Interpreting (“VRI ”).  When using VRI services, Swedish First Hill shall ensure that it provides:
1. Real-time, full-motion video and audio over a dedicated high-speed, wide- bandwidth video connection or wireless connection that delivers high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication;
2. A sharply delineated image that is large enough to display the interpreter’s face, arms, hands, and fingers, and the participating individual’s face, arms, hands, and fingers, regardless of his or her body position;
3. A clear, audible transmission of voices; and
4. Adequate training to users of the technology and other involved individuals so that they may quickly and efficiently set up and operate the VRI. 28 C.F.R. § 36.303(f).

VRI shall not be used when it is not likely to ensure effective communication, for example, due to: (1) a patient’s limited ability to move his or her head, hands or arms; vision or cognitive issues; or significant pain; (2) space limitations in the room; (3) communications with the Patient or Companion and Medical Personnel reflect that the complexity of the medical issue requires an on-site interpreter ; or (4) any other time when there are indicators that VRI will likely not or is not providing effective communication.  Whenever VRI does not provide effective communication with a Patient or Companion who is deaf or hard of hearing, VRI shall not be used as a substitute for an on-site Qualified Interpreter. However, in such circumstances, VRI may be used to communicate with the Patient or Companion until an on-site Qualified Interpreter can be requested and provided.  The on-site Qualified Interpreter shall be requested and provided in a timely manner as required by Paragraph 28 of this Agreement.  In such instance, the two hours begins when it becomes evident to Swedish First Hill Personnel that VRI cannot provide effective communication for that interaction or when a Patient or Companion first requests an on-site Qualified Interpreter.

28. Provision of Interpreters in a Timely Manner. 
1. Short Notice Interpreter Requests: A “short notice interpreter request” means a request for an interpreter made by a Patient or Companion who is deaf, deaf-blind, or hard of hearing less than seventy two (72) hours before the Patient’s appearance at Swedish First Hill for examination or treatment. For short notice interpreter requests, Medical Personnel will complete the assessment described in Paragraph 19 above.
• A Qualified Interpreter (via VRI) will be provided as soon as practicable, but no more than 30 minutes from the time Swedish First Hill completes the assessment (absent exigent circumstances affecting patient care which may extend the time for providing such service).
• In the event that an on-site Qualified Interpreter is required, an interpreter will be provided as soon as practicable, but no more than two (2) hours from the time it becomes clear that a live interpreter is necessary for effective communication.

As described below in Section (c) of this Paragraph, Swedish First Hill will document the on-site interpreter service’s response time, including the time of contact and the time of arrival.  Deviations from this response time will be addressed with the interpreting service provider, and performance goals will be reviewed with the U.S. Attorney’s Office every six (6) months, pursuant to Paragraph 42. If no Qualified Interpreter can be located, Medical Personnel will:

1. Exert reasonable efforts (which shall be deemed to require no fewer than five (5) telephone inquiries and/or emails and/or text messages unless exceptional circumstances intervene) to contact any Qualified Interpreters or interpreting agencies already contracted with the Hospital and request their services;
2. Inform the ADA Communications Services Resource Designee (s) of the efforts made to locate an interpreter and solicit assistance in locating an interpreter;
3. Inform the Patient or Companion (or a family member or friend, if the Patient or Companion is unavailable) of the efforts taken to secure a Qualified Interpreter and that the efforts have failed, and follow up on reasonable suggestions for alternate sources of Qualified Interpreters; and
4. Document all of the above efforts.
5. If reporting reveals a small number of incidents (i.e. 1-2 per reporting period) involving minor delay beyond these timeframes (i.e. less than 2 hours of additional delay for sign language and less than 30 minutes additional delay for VRI), the parties will work in good faith to identify and address the root cause. If no agreement for remediation can be reached, only then will such violations be considered a breach of this Agreement triggering the enforcement provisions of Paragraph 51.
2. Advanced Notice Interpreter Requests. An “advanced notice interpreter request” is a request for an interpreter made seventy two (72) or more hours before the services of the interpreter are required.  For advanced notice interpreter requests, Swedish First Hill Personnel will complete the assessment described in Paragraph 19 above in advance, and, when a Qualified Interpreter is appropriate, Swedish First Hill will make a Qualified Interpreter available at the time of the scheduled appointment.  If a Qualified Interpreter fails to arrive for the scheduled appointment, upon notice that the Qualified Interpreter failed to arrive, Swedish First Hill will immediately call the interpreter service for another Qualified Interpreter and comply with the timeframes set forth in Paragraph 28 (a).  To avoid delay in care to the patient, Swedish First Hill Personnel will consult with the Patient or Companion to provide alternative Auxiliary Aids and Services to assure effective communication while a substitute Qualified Interpreter is requested.
3. Data Collection on Interpreter Response Time.  Swedish First Hill will monitor and document in the Auxiliary Aid and Service Log, described in Paragraph 22, the response time of each Qualified Interpreter service it uses to provide communication to Patients or Companions who are deaf, deaf-blind, or hard of hearing through its established process of monitoring outside vendors.  Swedish First Hill will document and investigate, per the complaint resolution process identified in Paragraph 23, any Complaints by the Patients or Companions who are deaf, deaf-blind, or hard of hearing regarding the quality and/or effectiveness of services provided by the interpreter service.
4. Impact of Compliance with the Terms of this Paragraph.  If Swedish First Hill complies with the terms of Paragraph 28, it shall not be considered to be in breach of this Agreement for failure to provide a timely interpreter.  However, compliance with these terms does not necessarily constitute compliance with the terms of the ADA and Swedish First Hill may, therefore, still be subject to liability.
29. Notice to Patients and Companions Who are Deaf, Deaf-Blind, or Hard of Hearing.  As soon as Swedish First Hill Personnel have determined that a Qualified Interpreter is necessary for effective communication with a Patient or Companion who is deaf, deaf-blind, or hard of hearing, Swedish First Hill will inform the Patient or Companion (or a family member or friend, if the Patient or Companion is not available) of the current status of efforts being taken to secure a Qualified Interpreter on his or her behalf.  Swedish First Hill will provide additional updates as appropriate and feasible to the Patient or Companion until an interpreter is secured.  Notification of efforts to secure a Qualified Interpreter does not lessen Swedish First Hill’s obligation to provide Qualified Interpreters in a timely manner as required by Paragraph 28 of this Agreement.
30. Other Means of Communication.  Swedish First Hill agrees that between the time an interpreter is requested and the interpreter is provided, Medical Personnel will continue to try to communicate with the Patient or Companion who is deaf, deaf-blind, or hard of hearing for such purposes and to the same extent as they would have communicated with the person but for the disability, using all available methods of communication, for example, using written materials, exchange of written notes, video text displays, or other similar services and actions.   This provision in no way lessens Swedish First Hill’s obligation to provide Qualified Interpreters in a timely manner as required by Paragraph 28 of this Agreement.
31. Restricted Use of Certain Persons to Facilitate Communication.  Swedish First Hill will not rely on an adult friend or family member of the Patient or Companion who is deaf, deaf-blind, or hard of hearing to interpret except:
1. In an emergency involving an imminent threat to the safety of an individual or the public where there is no interpreter available; or
2. Where the Patient or Companion who is deaf, deaf-blind, hard of hearing specifically requests that the adult friend or adult family member interpret, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.  A Qualified Interpreter is required for the situations listed in Paragraph 25.

Swedish First Hill will not rely on a minor child of Patient to interpret except in the limited circumstances described in (a) above.

4. Notice to the Community
32. Policy Statement.  Within ninety (90) days of the entry of this Agreement, Swedish First Hill shall post and maintain signs of conspicuous size and print at all Swedish First Hill admitting areas and wherever a Patient’s Bill of Rights is required by law to be posted, with substantially similar language to that provided in the Sample Posting attached as Exhibit B notifying the public of the availability of Auxiliary Aids and Services and their related rights.  These signs will include the international symbol for “interpreter.”
33. Website.  Within ninety (90) days of the entry of this Agreement, Swedish First Hill will include on its website at this location: https://www.swedish.org/patient-visitor-info/accessibility the same or substantially similar policy statement and information regarding how to request Auxiliary Aids or Services and information regarding how to file a complaint with the hospital, through its complaint process, and through ada.gov.  Further, all new and redesigned web pages, web applications, and web content (“Web Pages ”) published by Swedish First Hill must act in accordance with the Web Content Accessibility Guidelines 2.0 principles of Perceivable, Operable, Understandable and Robust.
34. Patient Rights.  Swedish First Hill will include in all future revisions of its Patient Rights (or equivalent) and all similar publications a statement to the following effect:

    To ensure effective communication with Patients and their Companions who are deaf, deaf-blind, hard-of-hearing, we provide appropriate auxiliary aids and services free of charge to the Patient or Companion.

    Please ask your nurse or other Medical Personnel for assistance or if you have questions or concerns.

Swedish First Hill will also include in its Patient Rights a description of its complaint resolution mechanism.

5. Policy Revisions
   35. Policy Revisions.  Swedish First Hill will revise its policies to be consistent with ADA requirements regarding effective communication and the terms of this Agreement.  Such revisions must be provided to the United States within thirty (30) days of this Agreement for review.  Once approved by the United States, the policy will be distributed to Swedish First Hill Personnel and all Active Members of the Medical Staff in accordance with the timelines set forth in the Notice and Training sections that follow.
6. Notice to Swedish First Hill Personnel
   36. Intranet.  Within sixty (60) days of the entry of this Agreement, Swedish First Hill will publish on its intranet a policy statement regarding Swedish First Hill’s policy for effective communication with persons who are deaf, deaf-blind, or hard of hearing.  This policy statement includes, but is not limited to, language to the following effect:

   If you recognize or have any reason to believe that a Patient or a relative, close friend, or Companion of a Patient is deaf, deaf-blind, or hard-of-hearing, you must advise the person that appropriate auxiliary aids and services will be provided free of charge to the Patient or Companion.  If you are the responsible health care provider, you must ensure that such aids and services are provided when appropriate.  All other personnel should direct that person to the appropriate ADA Communication Services Resource Designee(s) at who is reachable at                 .

   37. Notice to Personnel.  Within thirty (30) days of the approval of policy revisions referenced in Paragraph 35, Swedish First Hill will distributed its policy/policies relating to effective communication with individuals who are deaf, deaf-blind, or hard of hearing to all Medical Personnel and Active Members of the Medical Staff. The policy will also be provided to all newly hired Medical Personnel and all Active Members of the Medical Staff upon their affiliation or employment with Swedish First Hill.
7. Training
   38. Training of the ADA Communication Services Resource Designee(s).  Swedish First Hill will provide mandatory training for the ADA Communication Services Resource Designee(s) as set forth in Paragraph 21 of this Agreement.  Such training must be provided to the United States within thirty (30) days of this Agreement for review.  Once approved by the United States, the training will occur within thirty (30) days.  Such training will be sufficient in duration and content to train the  ADA Communication Services Resource Designee(s) in the following areas:
   1. to promptly identify communication needs of Patients and Companions who are deaf, deaf-blind, or hard of hearing, including when an in-person Qualified Interpreter is necessary;
   2. to secure Qualified Interpreter services or VRI services as quickly as possible when necessary and how to do so;
   3. to use, when appropriate, other available means of communication that will augment the effectiveness of the communication;
   4. how, when, and when not to use VRI services;
   5. to encourage Active Members of Swedish First Hill’s Medical Staff to notify the  ADA Communication Services Resource Designee(s) of Patients and Companions who are deaf, deaf-blind, or hard of hearing as soon as Patients schedule admissions or other health care services at Swedish First Hill; and
   6. Swedish First Hill’s complaint resolution procedure described in Paragraph 23 of this Agreement.
   39. Training of Swedish First Hill Personnel.  Except for Active Members of the Medical Staff, who are governed by Paragraph 40 of this Agreement, Swedish First Hill will provide mandatory in-service training (on-line or otherwise) to all Swedish First Hill Personnel who have contact with Patients.
   1. The training will address the needs of Patients and Companions who are deaf, deaf-blind, or hard of hearing and will include the following objectives:
   1. to promptly identify communication needs of Patients and Companions who are deaf, deaf-blind, or hard of hearing, including when an in-person Qualified Interpreter is necessary;
   2. to secure Qualified Interpreter services or VRI services as quickly as possible when necessary and how to do so;
   3. to use, when appropriate, flash cards and/or pictographs (in conjunction with any other available means of communication that will augment the effectiveness of the communication); and
   4. how, when, and when not to use VRI services.
   2. Such training must be provided to the United States within thirty (30) days of this Agreement for review.  Once approved by the United States, the training will occur within sixty (60) days.
   3. New employees hired after this training is approved, must receive this training within thirty (30) days of their hire.
   40. Training of Active Members of the Medical Staff.  Within thirty (30) days of the United States’ approval of the policy revisions referenced in Paragraph 35, Swedish First Hill will provide Active Members of the Medical Staff of its policy/policies relating to effective communication with Patients or Companions who are deaf, deaf-blind, or hard of hearing, along with an advisement that:
   1.  indicates the additional availability of the policy on the intranet,
   2. request that the recipient reach out to the  ADA Communication Resources Designee(s) if they have questions about the policy and provide his or her contact information; and
   3. request that if and when they become aware that a Patient or Companion who is deaf, deaf-blind, or hard of hearing will be visiting Swedish First Hill for health care services, that they promptly follow Swedish First Hill process and procedures to request necessary Auxiliary Aids and Services.
   41. Training Attendance Records.  Swedish First Hill will maintain for the duration of this Agreement, confirmation of training conducted pursuant to Paragraph 38-40 of this Agreement, which will include the names and respective job titles of the attendees, as well as the date and time of the training session.  Swedish First Hill will also include in each of its Compliance Reports (Paragraph 42), an attestation that it has complied with the training and notice requirements of Paragraphs 38-40 of this Agreement or an explanation of how it has departed from such requirements, why, and what remedial measures to address the deficiency are being taken.
8. Reporting, Monitoring, and Violations
42. Compliance Reports.  Beginning six (6) months after the Effective Date of this Agreement and every six (6) months thereafter for the entire duration of the Agreement, Swedish First Hill will provide a written report (“Compliance Report”) to the U.S. Attorney’s Office regarding the status of its compliance with this Agreement.  The Compliance Report will include data relevant to the Agreement, including but not limited to:
1. information required in Auxiliary Aid and Service Log described in Paragraph 22;
2. information maintained in the complaint records described in Paragraph 23, including the number of complaints received by Swedish First Hill from Patients and Companions who are deaf, deaf-blind, or hard of hearing regarding Auxiliary Aids and Services and/or effective communication, and the resolution of such complaints including any supporting documents; and
3. information regarding training compliance as described in Paragraph 41.

Swedish First Hill will maintain records to document the information contained in the Compliance Reports and will make them available, upon request, to the U.S. Attorney’s Office.

43. Complaints.  During the term of this Agreement, Swedish First Hill will notify the U.S. Attorney’s Office if any person files a lawsuit, complaint, or formal charge with a state or federal agency, alleging that Swedish First Hill failed to provide Auxiliary Aids and Services to Patients or Companions who are deaf, deaf-blind, or hard of hearing or otherwise failed to provide effective communication with such Patients or Companions.  Such notification must be provided in writing via certified mail within twenty (20) days of the date Swedish First Hill received notice of the allegation and will include, at a minimum, the nature of the allegation, the name of the person making the allegation, and any documentation of the allegation provided by the complainant.  Swedish First Hill will reference this provision of the Agreement in the notification to the U.S. Attorney’s Office.
5. MONTETARY RELIEF
44. Payment to the United States in Lieu of Civil Penalty.  Within thirty (30) days of the Effective Date of this Agreement, Swedish First Hill will pay the United States FIFTY THOUSAND DOLLARS $50,000 to vindicate the public interest for the alleged violations of Title III of the ADA contained herein. Full payment will be made by electronic funds transfer pursuant to instructions to be provided by the United States Attorney’s Office for the Western District of Washington.
45. Compensatory Relief for D.A.  Within thirty (30) days after receiving the executed Agreement and D.A.’s signed release (a Blank Release Form is at Exhibit C), Swedish First Hill will pay D.A. FIFTY THOUSAND DOLLARS ($50,000). This payment is compensation to Complainant D.A. pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in Paragraphs 7 and 8. Full payment will be made by electronic funds transfer pursuant to instructions to be provided by the United States Attorney’s Office for the Western District of Washington.
46. Compensatory Relief for D.A’s Companion. Within thirty (30) days after receiving the executed Agreement and D.A. Companion’s signed release (a Blank Release Form is at Exhibit C), Swedish First Hill pay D.A.’s Companion TEN THOUSAND DOLLARS ($10,000). This payment is compensation to D.A.’s Companion pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in Paragraphs 7 and 8. Full payment will be made by electronic funds transfer pursuant to instructions to be provided by the United States Attorney’s Office for the Western District of Washington.
47. Compensatory Relief for J.A.  Within thirty (30) days after receiving the executed Agreement and J.A.’s signed release (a Blank Release Form is at Exhibit C), Swedish First Hill will pay J.A. FIFTEEN THOUSAND DOLLARS ($15,000). This payment is compensation to Complainant J.A. pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in Paragraphs 7 and 8. Full payment will be made by electronic funds transfer pursuant to instructions to be provided by the United States Attorney’s Office for the Western District of Washington.
48. Compensatory Relief for B.V.  Within thirty (30) days after receiving the executed Agreement and B.V.’s signed release (a Blank Release Form is at Exhibit C), Swedish First Hill pay B.V. FIFTEEN THOUSAND DOLLARS ($15,000). This payment is compensation to Complainant B.V. pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in Paragraphs 7 and 8. Full payment will be made by electronic funds transfer pursuant to instructions to be provided by the United States Attorney’s Office for the Western District of Washington.
6. ENFORCEMENT AND MISCELLANEOUS PROVISIONS
49. Duration of the Agreement.  This Agreement will be in effect for three (3) years from the Effective Date.  The “Effective Date” of the Agreement shall be the date upon which the last signature hereto was executed.
50. Enforcement.  In consideration of the terms of this Agreement as set forth above, the United States agrees to refrain from undertaking further investigation or from filing a civil suit under Title III in this matter, except as provided in Paragraph 51. Nothing contained in this Agreement is intended or shall be construed as a waiver by the United States of any right to institute proceedings against Swedish First Hill for violations of any statutes, regulations, or rules administered by the United States or to prevent or limit the right of the United States to obtain relief under the ADA for violations unrelated to this matter.
51. Compliance Review and Enforcement.  The United States may review compliance with this Agreement at any time and can enforce this Agreement if the United States believes that it or any requirement thereof has been violated by instituting a civil action in U.S. District Court.  If the United States believes that this Agreement or any portion of it has been violated, it will raise its claim(s) in writing with Swedish First Hill, and the parties will attempt to resolve the concern(s) in good faith.  The United States will allow Swedish First Hill thirty (30) days from the date it notifies Swedish First Hill of any breach of this Agreement to cure said breach, prior to instituting any court action to enforce the ADA or the terms of the Agreement.
52. Entire Agreement.  This Agreement and the attachments hereto constitute the entire agreement between the parties on the matters raised herein, and no other statement, promise, or agreement, either written or oral, made by either party or agents of either party, that is not contained in this written agreement, shall be enforceable.  This Agreement is limited to the facts set forth herein and does not purport to remedy any other potential violations of the ADA or any other federal law.
53. COVID-19. Delays in, partial, incomplete or non-performance of any provision of this Agreement by reason of government orders or other regulatory requirements concerning COVID-19 or risks of communication thereof, is not a breach of this Agreement, provided Swedish First Hill provide the United States reasonably timely notice of such excused non-performance and resumes full performance as soon as reasonably practical thereafter.
54. Binding.  This Agreement is final and binding on the parties, including all principals, agents, executors, administrators, representatives, successors in interest, beneficiaries, assigns, heirs, and legal representatives thereof.  Each party has a duty to so inform any such successor in interest.
55. Non-Waiver.  Failure by any party to seek enforcement of this Agreement pursuant to its terms with respect to any instance or provision shall not be construed as a waiver to such enforcement with regard to other instances or provisions.
56. Execution.  This Agreement may be executed in counterparts, each of which constitutes an original and all of which constitute one and the same Agreement.  Electronically transmitted signatures shall constitute acceptable, binding signatures for purposes of this Agreement.