ahrq's new tools to improve safety for patients with limited english proficiency march 14, 2013

AHRQ's new tools to improve safety for patients with Limited English Proficiency

March 14, 2013

Abt Associates | pg 2

Cindy BrachAgency for Healthcare Research and Quality

Joseph BetancourtDisparities Solutions Center

Melanie WassermanAbt Associates

Alexander GreenDisparities Solutions Center


One more collaborator Emils, born 10/10/2012


Presentation goals Describe development and testing of 2 AHRQ tools

to improve LEP patient safety:

– TeamSTEPPS Training module

– Guide for Hospital Leaders

Describe implementation successes and challenges

Hear from you whether/how you might use the tools


Background

8.5% of the U.S. population has limited English proficiency (LEP) (US Census Bureau, 2010)

Patient safety events more severe and more often due to communication errors for LEP patients (Divi et al. 2006, Flores 2005)


Background (Cont’d)

LEP patients are safer and have fewer readmissions with professional interpreters (Flores et al. 2003, 2005, Linholm et al. 2012)

Health care providers often try to “get by” without interpreters (Diamond et al. 2009; Ring et al. 2010)

This can cost hospitals millions (Price-Wise 2008; Quan 2010; Carbone et al. 2003)

Even when interpreters are present, they may not be empowered to speak up when they see a patient safety risk (Betancourt et al. 2012)


AHRQ’s response

Commissioned an evidence-based Hospital Guide and TeamSTEPPS training module to improve LEP patient safety

TeamSTEPPs is AHRQ and DoD’s patient safety initiative

These are the first patient safety tools designed for LEP patients


Preliminary Research Questions How do language barriers and cultural factors

contribute to potential patient safety events?

How are hospitals addressing linguistic and cultural sources of error?

Which trainable team behaviors and hospital-level changes can improve LEP patient safety?


Preliminary Research

Background Tool Development

Environmental Scan

Adverse Events Database

Qualitative Interviews with Interpreters, Frontline Staff & Hospital Leaders

Town Hall Meeting

TeamSTEPPS Module

Hospital Guide

Interpreter pilot


Findings

Environmental scan results reported above

Stratified adverse events database analysis:

– Less productive than anticipated due to data challenges:

• No standard field for patient language

• No field to record interpreter presence/absence

– Hospitals at Town Hall meeting reported similar data challenges


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Interpreter pilot and qualitative interviews

Common system failures:

– Late or wrong identification of patient language needs

– Non-qualified or non-use of interpreter

– Failure to address interpreter shortages

– Failure to integrate interpreter into patient safety team

Many stories about “close calls” or risky situations due to these issues


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Late or wrong identification of language needs Surgery intake in English latex allergy almost missed,

caught by interpreter called in at the last moment

Interpreter present but provider refusing their services

Wrong language used (Spanish/Portuguese, French/Creole)

In French, estomac is the stomach, but in Creole, lestomak mwen means, ‘my chest’. Without an interpreter present, a French-speaking provider could incorrectly think a patient was experiencing stomach pain, not chest pain. This is a potentially life-threatening error.

— Interpreter


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“I try to say, ‘The interpreter’s coming.’ I try to stall. But it’s hard when somebody’s pushing and saying, ‘I have to go. My family member has been here waiting with me for the interpreter…’ ”

—Nurse

Maybe somebody else requires that bed. So that’s when we do our discharge. I would like to see the doctor’s face if I go over there, and say, ‘you know, I really can’t discharge this patient because he doesn’t really understand anything’

—Nurse

Non-use of interpreter; failure to address shortages


I have noticed that the patients come back to the hospital, to the same units where they have already been discharged. So you give the paperwork to the patient the day that they are going home. Suppose I did not speak the language. The patient actually said, “yes yes yes yes I understand everything”. And then you find the patient back a few days later, a week later…the same patient. And then, that’s when I find out that every discharge instruction that was given to the patient was totally…it was just…it didn’t work at all.

—Nurse


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“I’ve seen interpreters try, for example, to intervene when a provider insists on speaking a language they’re not fluent in. And there’s a big power struggle and the interpreters feel intimidated. But it’d be nice for them to be able to really recognize situations that are really critical, to be able to call time outs”

— Interpreter Services leader

“The role of the interpreter is what we call black box. The role…is to render the words only” — Patient safety leader

Failure to integrate interpreter into patient safety team


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Improve LEP safety by helping hospital leaders to:

Foster a Supportive Culture for Safety of Diverse Patient Populations.

Adapt Current Systems To Better Identify Medical Errors Among LEP Patients.

Improve Reporting of Medical Errors for LEP Patients.

Routinely Monitor Patient Safety for LEP Patients.

Address Root Causes To Prevent Medical Errors Among LEP Patients

Hospital Guide Goals


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What we know about LEP and patient safety

Strategies and tools to improve patient safety systems

Team behaviors to improve LEP patient safety

Additional resources and case examples

Hospital Guide Content


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Hospital Guide Testing

Shared with leaders in quality and safety at 9 hospitals

Leaders shared with their implementation teams (eg: interpreter leads, nursing leads)

Structured 30 mn interviews with leaders about content, usability, ease of implementation, and overall design and structure

Qualitative data analysis to identify key themes and implications for hospital guide

Edits made accordingly


Module Goals and Content Goals: help hospital staff to improve LEP safety by:

– Understanding risks to LEP patients

– If LEP calling a professional medical interpreter

– Identifying and raising patient communication issues

Content:

– Customizable PowerPoint slides, videos, exercises

– Structured communication tools

– Evaluation guide


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Process Map Exercise


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Stop the Line: Use CUS Words

• Structured communication tool to flag patient safety risks • Empowers everyone on the team to stop the line • Cues everyone on the team to pay attention if these words are used


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Check-Back Tool


Field Test

Case study design

– ToT, 5 month follow-up, field visit

Requirements to participate:

– No $ incentive

– Send 2 trainers to ToT

– Implement in at least 1 unit

– Train the entire team

– Evaluate


Successes Module implemented 3 hospitals

– Hospital #1: L&D

– Hospital #2: ED, OB/Gyn

– Hospital #3: Pediatric primary care

Focus of interventions:

– Hospital #1: Use of qualified communicator

– Hospital #2: Capturing patient preferred language

– Hospital #3: Use of phone-interpreters

268 staff members trained including doctors, nurses, interpreters, registration staff


Quantitative Results

Hospital #1

– Pre-test convinced leadership no post-test

Hospital #2

– High satisfaction (2.94 on 3-pt scale)

– Significant increase in knowledge (up 28 points on 100-pt scale)

– Race/ Ethnicity/Language (R/E/L) data quality issues behavior data unusable

Hospital #3

– High satisfaction (3 on 3-pt scale)

– Increase in knowledge scores (up 17.6 points on 100-pt scale)

– More phone interpreter minutes used but no LEP denominator


Qualitative Results Recognition of interpreter as cultural broker

Willingness to include interpreter in care team

Reliance on CUS words/other techniques

Increased use of phone line (Hospital #3)

Institutional changes

– Reallocation of interpreter resources (Hospital #1 & #3)

– Plans to update hospital interpreter policy

– Clarification of bilingual certification guidelines (Hospital #1)


Challenges

Time/cost concerns Competing quality initiatives Limited interpreter resources Staff turnover Equipment loss Data quality for evaluation Scale-up after the pilot


Practical advice Implement the Guide and module to improve LEP

safety

– May be helpful to implement Joint Commission standards on patient-centered communication

Use creative scheduling and persistence to overcome barriers of time, cost and competing initiatives

Use interpreter resource reallocation as a stopgap until shortages are addressed

Check data availability/quality before finalizing evaluation plan


Take-home tools Hospital Guide and Module available here:

http://www.ahrq.gov/legacy/teamsteppstools/lep/

http://www.ahrq.gov/legacy/teamsteppstools/lep/

Thank you!

ahrq's new tools to improve safety for patients with limited english proficiency march 14, 2013

Documents

lep patient safety

trained interpreters

interpreters vs

interpreters diamond

patient safety problems

patient safety events

lep patients divi

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