Loretta Saint-Louis, Ph.D. Cambridge Health Alliance IMIA October 2007 Improving Inpatient Language...

Loretta Saint-Louis, Ph.D.

Cambridge Health Alliance

IMIA October 2007

Improving Inpatient Improving Inpatient Language Access for Language Access for

Better, Patient-Centered Better, Patient-Centered Care: Partnering for Care: Partnering for

ProgressProgress

Key Concepts in Inpatient Language Access Improvement

• Patient-Centered care requires communication with the patient

• Improving language access improves care for LEP patients

• Language access requires collaboration between the manager, staff and providers of the inpatient unit and the manager and staff of interpreter services

• Improvement has to be collaborative

• Measurable quality improvement on measures clearly involving clinical care is most powerful

Partnering for Progress

Patient-Centered Care

• People are treated with dignity and respect

• Health care providers communicate information with patients and families in ways that are affirming and useful

• Individuals and families build on their strengths by participating in experiences that enhance control and independence

• Collaboration among patients, families, and providers occur in the delivery of care, policy and program development, and professional education*

*Source: Institute for Family-Centered Care


Patient-Centered Care and Safety

• Provider-initiated and patient-initiated communication

• Language access for both is a safety issue

• Joint Commission SPEAK UP Campaign

• Empower patients to ask questions!

• Help prevent errors in your care

• Help prevent mistakes in your surgery

• Help prevent infection

• Help avoid mistakes with your medication


Cambridge Health Alliance

• Academic Public Healthcare System• Cambridge, Somerville, Everett, Malden, Revere, Winthrop• Three acute care hospitals, 300 beds • 25 primary care sites• Interpreters on site at 12 sites, sent out• Public Health Department of Cambridge• Managed Care Medicaid Health Plan• Uncompensated Care Program


Linguistic Diversity at CHA

• 45% of patients have a primary language other than English

• 60+ languages in all, new languages arriving continuously

• Linguistically diverse work force

• Interpreter Services since 1970s


Languages of Interpreting at CHA55 others,

4.5%Hindi, 3%

Vietnamese, 3%

Haitian Creole, 8%

Spanish, 26%

Portuguese, 55%

PortugueseSpanishHaitian CreoleVietnameseHindi55+ others


Interpreter Services Capacity

• 50+ FTE’s permanent staff• 100+ per diem medical interpreters• 24/7 service• Interpreter Agencies• Internal ACD phone system• Language Line• Commission for the Deaf and Hard of Hearing &

Deaf Talk videoconferencing ASL interpreting• 170,000+ encounters in FY07• Interpreters enter encounters in database


• Haitian inpatient with pain

• A problem exposed

• Using the story to motivate change

• Applying for the grant

Inpatient Interpreter Access: The Wake Up Call


Language Access Improvement Projects

• Blue Cross Blue Shield Foundation of Massachusetts 2005 – 2006, Pathways to Culturally Competent Care

• Speaking Together Learning Collaborative in Quality Improvement, funded by Robert Wood Johnson Foundation 2006 - 2008


Objectives of Project: Pathways

1. Improve our understanding and response to inpatient communication needs.

2. Improve access to language services.3. Test new tools and processes for provider and

patient initiated interpreter requests.4. Improve cultural competency of inpatient unit


Objectives of Project: Speaking Together Inpatient Work

1. Measurable quality improvement in clinical care for LEP patients


Project Phases: Pathways

1. Needs Assessment June 05 – Dec 05

2. Pilot Implementation Jan 06 – March 06

3. Evaluation March 06 – June 06

4. Implementation in Med/Surg June 06 – April 07

5. Evaluation April – June 07


Project Phases: Speaking Together

1. Become familiar with 7 measures Dec – Jan 06

2. Master data collection Feb 06 – July 07

3. Quality Improvement Aug 07 – Feb 08


Participants/Stakeholders

Pathways • Patients• Interpreters• Providers• Nurses• Staff • Evaluation• Risk Management• Patient Relations• Translation Coordinator• Interpreter Managers



Pathways • Learned that Interpreter Managers and Nurse

Managers are key• Learned that a physician champion would be

helpful• Needed stronger quality improvement

component



Speaking Together • Interpreter managers and Interpreters• Providers, Nurse Managers, Nursing staff• Quality Management• Information Technology• Clinical Pharmacy • Physician Champion• Sr Vice President of Performance Improvement• Chief Nursing Officer• CEO• National Program Office of Speaking Together• 9 other hospitals in the Learning Collaborative


Pathways – Selecting the Pilot Unit

• 6 North at Cambridge Hospital

• Linguistic Diversity

• Nurse Manager engaged already in Quality Improvement

• Nurse Manager embraces cultural competency


Needs Assessment

• Baseline data• Interpreter encounters per inpatient day• Total interpreter encounters• 10 inpatient interviews (Portuguese, Spanish,

Haitian)• 2 focus groups with 6N providers and staff• 2 focus groups with medical interpreters• 1 online survey to reach other providers and staff• 1 online survey to reach other medical

interpreters


Needs Assessment Sample Findings

From the patients: “Sometimes I have trouble communicating. When I was

asked howI was feeling, I could not answer. I understand a little bit ofEnglish but I don’t speak it at all.”From the providers and staff: “The [interpreter] delay is critical sometimes.”From the medical interpreters:“I waste a lot of time looking for the provider and the

patient.”From review of volumes of interpretingLow ratios of interpretation activity per patient stay.


Linguistic Diversity at 6 North

• In 2005, 43% patients primary language other than English (up 10% from 2004)

• Interpreter encounters:• 759 in 2004 to • 1071 in 2005• 760: January – June 2006

• Language Distribution: Portuguese, Spanish, Haitian Creole, Hindi, Arabic, Korean, Mandarin, Amharic, Bengali, Italian, Nepalese, Punjabi, Russian, Somali, Urdu


Languages of Patients on 6 North

57%

21%

9%

5%

8%

English

Portuguese

Spanish

Haitian Creole

Others


Linguistic Diversity of Staff• 6N has 34 staff members• 50% Staff bilingual/multilingual• 33% of RNs, 80% of Nursing Assistants, 33% of Unit Secretaries

Staff Languages on 6N

01234567

Haitian

Cre

ole

Portu

gues

e

Man

adar

in

Frenc

h

Spanis

h

Italia

nIb

o

Yorub

a


How did we improve the experience of our patients who speak other languages?


Welcome Letter to Patients & Interpreter Request Cards

“Please call a medical interpreter so we can communicate better.”


Telephone Interpreting Equipment

Dual handset and full duplex speaker phone capability at each bedside to facilitate telephone interpreting.


“You have a right to a medical

interpreter at no cost to

you.”

30 Language DPH Poster


Translated Materials

Patient Education Materials clearly visible for nursing staff and providers. Several additional materials were translated.


Translated Materials Accessible to Patients

Patient Materials and brochures also available in hallway for patients and family access.


How did we raise the awareness and what user-friendly tools

did we provide for staff?


To call an interpreter any time, any site, any language

Call x3333

Dial 1 for a face-to-face interpreter

Dial 2 for a phone interpreter


• Portuguese• Arabic• Vietnamese• Chinese• Italian• Russian• Haitian• Spanish

Hospital Phrase Booklets


Locator Board Language Magnets

Language magnets easily identify patients that require interpreter assistance.


Communication to Staff

Provider Board

6N Newsletter

Emails

Staff meetings

CHA eBeat


• 2 in-services for interpreters (day & night)

• 2 in-services for 6N staff (day & night)

• Follow up meetings with interpreters

In-services for 6N and for Interpreters


Best situations for phone interpreting:• For quick, focused conversation• Patient-initiated conversation/comfort issue• ADLs, When the matter is logistical or simple to

explainBest situations for face-to-face interpreting:• For serious or bad news• For encounters that involve family discussion• For patient education • For confused or hard of hearing patients

Guidelines (phone vs. face-to-face)


Four 6N bilingual staff were tested for linguistic proficiency and basic interpretation ability.

The staff person who passed the test is the only one allowed to interpret for patients in the unit.

Bilingual Staff Proficiency Testing


• The majority of nursing staff at 6N completed the Quality Interactions Online Nursing Module, provided free of charge by Blue Cross Blue Shield of Massachusetts.

• Interactive program that provided pretest, education, three patient encounters, and a post test.

• Several providers completed the Quality Interactions Online Physician Module.

Cultural Competency Training


• Office of Minority Health best practices

• Introduce patient to interpreter services and teach them how to access interpreters

• Daily check in with patient about communication needs

• Identify individualized linguistic needs and collaborate with nursing staff

Inpatient Interpreter Rounds Empower Patients


• Point person for co-workers in addressing cultural and linguistic issues

• Helps ensure that their department meets the cultural and linguistic needs of patients.

• Works with their cultural supporter, Multilingual Interpreting, and others to implement improvements.

Cultural Ambassador at 6 North


Challenges for Interpreter Service

• Limited staff (timeliness and access)

• Simultaneous demands of all departments & sites

• Inpatient needs seen as less time sensitive than ambulatory and emergency departments

• Logistics of covering interpreter rounds

• Evening, overnight, and weekend coverage


Improved interpreter access

• Reprioritized interpreter dispatching for inpatients

• Posted Multilingual Manager pager numbers for delays over 15/30 minutes

• Staffed interpreter rounds, developed protocol

• Interpreters document in medical record with stickers readily available on the unit

• More complete information to interpreter on who needs them


• Inpatient personal interviews • Online survey for providers and staff • Online survey for interpreters • Press Ganey Quarterly Results• Interpreter Inpatient Reports Audit• Interpreter Round Observation • Periodic Data & Interpreter Activity Review• Encounter Statistics Reviews

Evaluation of Pilot


Periodic patient interviews (n=4)

• Increase of 50% on knowing of right to an interpreter

• Increase of 40% of patients interviewed not given cards

• 25% received translated materials (baseline none)

• 25% had interpreter round at least once (baseline 10%)

• 100% satisfied with timeliness (same as baseline)


• 50% utilized locator board• 37% had trouble accessing interpreters (baseline

71%)• 100% had used telephone interpreting

(speakerphone)• 75% had read face-to-face vs. telephone guidelines• 25% were shown interpreter request cards by

patients

Online provider/staff surveys (n=18)


• 75% said it was very or somewhat easy to interpret with the speakerphone/handset

• 40% unaware of changes at 6 North• 37.5% had not seen the locator board• 60% didn’t know name of Cultural Ambassador• 75% read interpreter round guidelines

Online interpreter surveys (n=28)


• 4 medical records are reviewed at a time (Haitian, Portuguese, Spanish, Hindi)

• Reviewed notes of interactions with patients and documentation of interpreter present

• Compared to Multilingual Departments’ data on interpreted encounters with patients

• Primary findings: low utilization of medical interpreters and incomplete documentation on medical records

Medical Record Audits


• Pilot unit: 84% increase in interpreter encounters per inpatient day – from 0.9 in FY05 to 1.66 in FY07

• Increase in interpreter rounds • Increase in patient satisfaction• Gains on pilot unit spread to other units even

before formal implementation• Modest gains on other four units during

implementation year

BCBS Results


• Improvement work takes focused, prolonged attention, Project Manager

• Listen respectfully, learning the perspective of patients, providers, and staff on the unit

• Nurse managers and staff can best identify what will be useful to them

• Communication tips • Short, focused meetings at times that fit• Short, bullet points on documents

Lessons Learned


1. Create the team2. Plan regular meetings, weekly email3. Learn the shared measures, develop clinical

measures4. Get baseline measures5. Improve data collection6. Report data monthly7. Plan/Do/Study/Act Cycles to improve results

Speaking Together Steps


1. ST1 Language Identification2. ST2: Assessment and Discharge with Language3. ST3: Patient wait time for interpreter4. ST4: Interpreter work time interpreting5. ST5: Interpreter wait time6. CM 1: Depression screening for LEP amb

patients7. CM2: Rehospitalization in 30 days for CHF

patients

Speaking Together: Operations and Clinical Care

www.speakingtogether.org


Percent of LEP patients who received qualified language providers for both assessment and discharge, by language

With hospital interpreter ORWith bilingual provider who has passed a fluency

test

Speaking Together National Measure ST2


Data: interpreter encounter database with coded assessment and discharge encounters, medical records, Meditech, Language testing records of providers

Sources of data for ST2


• Timely interpreter access an issue for nurses – not aware of progress in dispatching interpreters

• Family members used• Gaps in data entry in interpreter encounter

database

Results on ST2: Most inpatients not getting qualified language service for both assessment and discharge


• Communication campaign on the inpatient units• Quickly and visibly reward nurses for calling

interpreters for assessment and discharge• Aim for the tipping point• Complete data entry in interpreter encounter

data base• Complete documentation of how the language

need was met in the medical record

Next steps


• Interpreter service sees what we provide – not what we miss

• We miss a lot!!! Family members used frequently

• Focused collaboration is necessary for improvement

• Provide protected time for project• Create a safe environment for discussions both

within and across departmental lines• A physician champion engages providers• Provider time most limited of all!

More Lessons Learned


• Special thanks to Izabel Arocha, the project manager on the BCBS grant, and to Jacque Caglia, the project manager for Speaking Together

• Special thanks to Laurie Bausk, RN, Nurse Manager, and the staff of 6 North at Cambridge Hospital

• Special thanks to Donna Cole, RN, and Alice O’Brien,RN, Nurse managers on West 3 and Lewis 1 at Whidden Hospital, and to your staff

• Many thanks to the managers of Multilingual Interpreting, Cristina DeAlmeida, Milca Ortiz-Rivera, and Avlot Quessa, and to the interpreters and dispatchers of the Multilingual Interpreting team who provide language access around the clock at CHA. You are champions of patient-centered care!

Thanks


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Loretta Saint-Louis, Ph.D. Cambridge Health Alliance IMIA October 2007 Improving Inpatient Language...

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