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
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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
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45% of patients have a primary language other than
English
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60+ languages in all, new languages arriving continuously
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Linguistically diverse work force
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Interpreter Services since 1970s
Partnering for Progress
Languages of Interpreting at CHA
Hindi, 3%
Vietnamese,
3%
Haitian
Creole, 8%
55 others,
4.5%
Portuguese
Spanish
Haitian Creole
Vietnamese
Hindi
55+ others
Portuguese,
55%
Spanish,
26%
Partnering for Progress
Interpreter Services Capacity
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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
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Patients
Interpreters
Providers
Nurses
Staff
Evaluation
Risk Management
Patient Relations
Translation Coordinator
Interpreter Managers
Partnering for Progress
Participants/Stakeholders
Pathways
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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
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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
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6 North at Cambridge Hospital
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Linguistic Diversity
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Nurse Manager engaged already in Quality
Improvement
Nurse Manager embraces cultural competency
Partnering for Progress
Needs Assessment
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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
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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
M
ub
a
Yo
r
o
Ib
lia
n
Ita
ni
sh
Sp
a
ch
Fr
en
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Po
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tu
gu
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le
C
re
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H
ai
tia
ar
in
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6
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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
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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
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2 in-services for interpreters (day & night)
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2 in-services for 6N staff (day & night)
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Follow up meetings with interpreters
Partnering for Progress
Guidelines (phone vs. face-to-face)
Best situations for phone interpreting:
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For quick, focused conversation
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Patient-initiated conversation/comfort issue
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ADLs, When the matter is logistical or simple to
explain
Best situations for face-to-face interpreting:
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For serious or bad news
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For encounters that involve family discussion
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For patient education
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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
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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.
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Interactive program that provided pretest,
education, three patient encounters, and a post
test.
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Several providers completed the Quality
Interactions Online Physician Module.
Partnering for Progress
Inpatient Interpreter Rounds
Empower Patients
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Office of Minority Health best practices
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Introduce patient to interpreter services and teach
them how to access interpreters
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Daily check in with patient about communication needs
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Identify individualized linguistic needs and collaborate
with nursing staff
Partnering for Progress
Cultural Ambassador at 6 North
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Point person for co-workers in addressing
cultural and linguistic issues
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Helps ensure that their department meets the
cultural and linguistic needs of patients.
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Works with their cultural supporter, Multilingual
Interpreting, and others to implement
improvements.
Partnering for Progress
Challenges for Interpreter Service
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Limited staff (timeliness and access)
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Simultaneous demands of all departments & sites
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Inpatient needs seen as less time sensitive than
ambulatory and emergency departments
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Logistics of covering interpreter rounds
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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
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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)
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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)
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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)
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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!