In-Person Interpreter Participation during
Morning Rounds Changes Patient Management
on the Pediatric Inpatient Ward
Vivian Wang, BA; Larissa Wenren, BA; James Moses, MD, MPH; Christine Cheston, MD
BACKGROUND
RESULTS
• Healthcare disparities between limited English proficiency (LEP)
and English proficient (EP) patients in pediatrics are well
described1-3
• Data suggest that professionally trained in-person interpreters
(IPIs) can best minimize these disparities when compared to adhoc and phone interpreters4
• Before October 2014, the BMC pediatric inpatient ward had 30%
of patients with LEP but no system in place for utilizing IPIs
during daily family-centered morning rounds
• Without IPIs, the benefits of family-centered care plan
discussions did not reach LEP patients and families
• Our intervention addresses this disparity by providing IPIs to
achieve equitable, patient-centered care for LEP patients and
families on the inpatient pediatric ward
• 530 confirmed morning rounding encounters with IPIs since start of initiative
• 62% of LEP rounding encounters had care plans discussed in the family’s preferred
language with an IPI during most recent PDSA cycle, up from 0% at baseline
• 20% of IPI encounters have been associated with a change in management
• Form completion rates highest with weekly in-person and email check-ins with trainees
• No difference in average reported rounding time with or without IPIs (average 2 hrs 8 mins)
• Patient satisfaction for LEP patients was high and comparable to EP patients during data
collection through November 2015
• To increase the percentage of morning rounding
encounters with professional IPIs for LEP families on
the pediatric inpatient ward to 75% by January 1st,
2017
PDSA 1-3
PDSA 4
PDSA 5
PDSA 6
PDSA 7
• Implemented new
• Simplified
• Integrated QI
• Modified IPI • Attempted
system and form used
data
initiative as part
time requests sustainability by
to schedule IPIs
collection
of curriculum for
by
discontinuing
• Recruited medical
form
students
negotiating
check-ins
student involvement
• Began
• Initiated weekly
arrival times • Returned to
• Refined
tracking form
feedback emails • Began
previous method
communication
completion
to trainees
weekly inof requesting
processes with IPI and rates weekly
person
specific IPI
team orientation
check-ins
arrival time
Figure 4: Percentage of Morning Rounding Encounters during which
Patients and Families with Limited English Proficiency with Care Plan
discussed with In-Person Interpreter
Primary Project
Outcome Measure
• Proportion of LEP patient morning rounding
encounters in which a provider communicated the
care plan through an IPI
Secondary Project
Outcome Measure
• Proportion of rounding encounters where changes
in management ensued because of
communication through IPI
Process Measures
• Proportion of interpreter rounding forms completed
• Proportion of written and verbal sign-outs including
preferred language
Balancing
Measure
% of encounters with LEP families using IPI
METHODS
• We used the Institute for Healthcare Improvement’s Model of
Improvement, Plan-Do-Study-Act cycles, and run chart analysis
• Baseline data was collected September-October 2014
• Post-intervention data was collected October 2014 through
August 2016 through daily forms completed by the medical team
(see Figure 2) and patient satisfaction surveys
100%
Baseline
PDSA 1-3
Goal for IPI Utilization
PDSA 4
PDSA 5
Primary Drivers
In-person
interpreters
scheduled for
morning rounds
Medical team
makes languageconcordant care
a high priority for
quality and safety
Families present
for familycentered rounds
Resident and medical student orientation
to disparities and project components
Include language as its own field in written
sign-outs and note language for all
patients during verbal sign-outs
Introduce orientation/video to families
about rounds
PDSA 7
PDSA 8
100%
80%
70%
70%
60%
60%
50%
50%
40%
40%
30%
30%
20%
20%
10%
10%
0%
0%
Month
Figure 5: Completion Rates of Implemented Rounding Forms
by Medical Team
Median for Completion Rate
Introduce standardized form to schedule
interpreters for rounds
Form team with Interpreter Services, RN
Manager, and Unit Coordinator
PDSA 6
Change in Management with IPI
80%
Potential Interventions
Enlist medical students to complete
rounding form
IPI Utilization
90%
• Patient satisfaction with communication
• Rounding time
Goal for Completion Rate (100%)
Form Completion Rate
100%
% of daily rounding forms completed
Increased
participation of
in-person
interpreters
during care plan
conversations
with LEP
patients during
family-centered
morning rounds
Median for IPI Utilization
90%
Figure 1: Driver Diagram
Outcome
PDSA 8
• Reimplemented
weekly email
check-ins
• Refined
rounding form
• Removed
request time
for IPIs
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
PDSA 6 Pre
PDSA 1-3
PDSA 4
PDSA 5
PDSA 6
PDSA 7
PDSA 8
Week
Figure 2: Current Form Used for Identifying LEP Patients,
Requesting IPIs for Morning Rounds, and Tracking Measures
CONCLUSIONS
• Maintaining the presence of an interpreter requesting system
significantly increased the use of interpreters during morning rounds at
our institution
• Despite the challenge of frequently rotating team members, culture
change promoting language-concordant care may be occurring
• Discussion of care plans with LEP patients in their preferred language
with in-person interpreters may be associated with changes in
management without increasing duration of rounds
NEXT STEPS
• Address optimal timing of encounters with interpreters through
continued collaboration with Interpreter Services
• Restart weekly in-person check-ins with medical team
• Continue working with the rapid turnover of medical students and
residents through improved orientation, culture change, and increased
awareness of the benefits of utilizing IPIs
REFERENCES
1.
2.
3.
4.
Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care
Res Rev. 2005;62: 255-299.
Cohen, A. L., et al. (2005). "Are language barriers associated with serious medical events in hospitalized pediatric
patients?" Pediatrics 116(3): 575-579.
Lion, K. C., et al. (2013). "Association between language, serious adverse events, and length of stay among
hospitalized children." Hosp Pediatr 3(3): 219-225.
Flores, G., et al. (2012). "Errors of medical interpretation and their potential clinical consequences: a comparison of
professional versus ad hoc versus no interpreters." Ann Emerg Med 60(5): 545-553.
% of encounters with management change due to IPI
AIM
Figure 3: PDSA Cycles Implemented