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Abt Associates | pg 2
Cindy BrachAgency for Healthcare Research and Quality
Joseph BetancourtDisparities Solutions Center
Melanie WassermanAbt Associates
Alexander GreenDisparities Solutions Center
Abt Associates | pg 4
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
Abt Associates | pg 5
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)
Abt Associates | pg 6
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)
Abt Associates | pg 7
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
Abt Associates | pg 8
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?
Abt Associates | pg 9
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
Abt Associates | pg 10
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
Abt Associates | pg 11
Abt Associates
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
Abt Associates | pg 12
Abt Associates
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
Abt Associates | pg 13
Abt Associates
“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
Abt Associates | pg 14
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
Abt Associates | pg 15
Abt Associates
“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
Abt Associates | pg 16
Abt Associates
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
Abt Associates | pg 17
Abt Associates
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
Abt Associates | pg 18
Abt Associates
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
Abt Associates | pg 19
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
Abt Associates | pg 21
Abt Associates
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
Abt Associates | pg 23
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
Abt Associates | pg 24
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
Abt Associates | pg 25
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
Abt Associates | pg 26
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)
Abt Associates | pg 27
Challenges
Time/cost concerns
Competing quality initiatives
Limited interpreter resources
Staff turnover
Equipment loss
Data quality for evaluation
Scale-up after the pilot
Abt Associates | pg 28
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
Abt Associates | pg 29
Take-home tools
Hospital Guide and Module available here:
http://www.ahrq.gov/legacy/teamsteppstools/lep/