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					      Improving Inpatient
Language Access for Better,
    Patient-Centered Care:
    Partnering for Progress
                  Loretta Saint-Louis, Ph.D.

                  Cambridge Health Alliance

                        IMIA October 2007
                Partnering for Progress
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
               Partnering for Progress

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
              Partnering for Progress

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
               Partnering for Progress


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
                     Partnering for Progress

              Languages of Interpreting at CHA
                  55 others,
      Hindi, 3%     4.5%                Portuguese
Vietnamese,                             Spanish
                                        Haitian Creole
     3%
                                        Vietnamese
  Haitian                               Hindi
Creole, 8%                              55+ others

                                      Portuguese,
                                         55%
   Spanish,
    26%
          Partnering for Progress

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
           Partnering for Progress

Inpatient Interpreter Access:
The Wake Up Call

• Haitian inpatient with pain

• A problem exposed

• Using the story to motivate change

• Applying for the grant
            Partnering for Progress


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
                Partnering for Progress

    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
            Partnering for Progress


Objectives of Project:
Speaking Together Inpatient Work


1. Measurable quality improvement in clinical care
   for LEP patients
                Partnering for Progress


 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
                Partnering for Progress

 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
             Partnering for Progress

Participants/Stakeholders
Pathways
 •   Patients
 •   Interpreters
 •   Providers
 •   Nurses
 •   Staff
 •   Evaluation
 •   Risk Management
 •   Patient Relations
 •   Translation Coordinator
 •   Interpreter Managers
             Partnering for Progress

Participants/Stakeholders
Pathways
 •   Learned that Interpreter Managers and Nurse
     Managers are key
 •   Learned that a physician champion would be
     helpful
 •   Needed stronger quality improvement
     component
              Partnering for Progress

Participants/Stakeholders
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
               Partnering for Progress

Pathways – Selecting the Pilot Unit

•   6 North at Cambridge Hospital

•   Linguistic Diversity

•   Nurse Manager engaged already in Quality
    Improvement

•   Nurse Manager embraces cultural competency
              Partnering for Progress

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
               Partnering for Progress
 Needs Assessment Sample Findings
From the patients:
“Sometimes I have trouble communicating. When I was
   asked how
I was feeling, I could not answer. I understand a little
   bit of
English 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 interpreting
Low ratios of interpretation activity per patient stay.
             Partnering for Progress


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
                Partnering for Progress

Languages of Patients on 6 North

           8%
      5%
                              English
 9%
                              Portuguese

                              Spanish
                        57%

21%                           Haitian Creole

                              Others
                             Partnering for Progress

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
     7
     6
     5
     4
     3
     2
     1
     0




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        Partnering for Progress




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

Welcome Letter to Patients & Interpreter Request
                  Cards

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


Telephone Interpreting Equipment

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

30 Language DPH Poster




                          “You have a
                           right to a
                            medical
                         interpreter at
                           no cost to
                             you.”
            Partnering for Progress

Translated Materials

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


Translated Materials Accessible to Patients


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




How did we raise the awareness
 and what user-friendly tools
   did we provide for staff?
       Partnering for Progress

       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
            Partnering for Progress


Hospital Phrase Booklets
•   Portuguese
•   Arabic
•   Vietnamese
•   Chinese
•   Italian
•   Russian
•   Haitian
•   Spanish
             Partnering for Progress

Locator Board Language Magnets


                                 Language
                                 magnets easily
                                 identify patients
                                 that require
                                 interpreter
                                 assistance.
           Partnering for Progress

Communication to Staff

                          Provider
                          Board
                          6N Newsletter
                          Emails
                          Staff
                          meetings
                          CHA eBeat
                   Partnering for Progress


    In-services for 6N and for Interpreters


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

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

•     Follow up meetings with interpreters
            Partnering for Progress

Guidelines (phone vs. face-to-face)

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


Bilingual Staff Proficiency Testing

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.
             Partnering for Progress


Cultural Competency Training
•   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.
             Partnering for Progress

Inpatient Interpreter Rounds
Empower Patients
•   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
              Partnering for Progress

Cultural Ambassador at 6 North

•   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.
              Partnering for Progress

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
              Partnering for Progress


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
              Partnering for Progress


    Evaluation of Pilot
•    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
              Partnering for Progress

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)
               Partnering for Progress


    Online provider/staff surveys (n=18)
•    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
               Partnering for Progress


    Online interpreter surveys (n=28)

•    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
             Partnering for Progress


Medical Record Audits
• 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
             Partnering for Progress


BCBS Results
• 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
             Partnering for Progress


 Lessons Learned

• 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
            Partnering for Progress


Speaking Together Steps

1. Create the team
2. Plan regular meetings, weekly email
3. Learn the shared measures, develop clinical
   measures
4. Get baseline measures
5. Improve data collection
6. Report data monthly
7. Plan/Do/Study/Act Cycles to improve results
            Partnering for Progress

Speaking Together: Operations and
Clinical Care

1. ST1 Language Identification
2. ST2: Assessment and Discharge with
   Language
3. ST3: Patient wait time for interpreter
4. ST4: Interpreter work time interpreting
5. ST5: Interpreter wait time
6. CM 1: Depression screening for LEP amb
   patients
7. CM2: Rehospitalization in 30 days for CHF
   patients
www.speakingtogether.org
             Partnering for Progress


Speaking Together National Measure ST2


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

With hospital interpreter OR
With bilingual provider who has passed a fluency
  test
              Partnering for Progress


 Sources of data for ST2

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

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

Next steps
• 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
             Partnering for Progress

More Lessons Learned
• 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!
               Partnering for Progress
  Thanks
• 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!

				
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