Ensuring Patient Safety for Language Ensuring Patient Safety for Language Minority PatientsMinority Patients

A New Standard of CareA New Standard of Care

Megan Renfrew, MAMegan Renfrew, MAMassachusetts General Hospital Massachusetts General Hospital

Disparities Solutions CenterDisparities Solutions Center

Melanie Wasserman, PhD, MPAMelanie Wasserman, PhD, MPA Abt Associates, Inc.Abt Associates, Inc.

Cambridge, MACambridge, MA

International Medical Interpreters Association Annual Conference September 2010

AHRQ Contract No. HHSA290200600011I, Task Order No. 9AHRQ Contract No. HHSA290200600011I, Task Order No. 9

Prevalence of LEP Prevalence of LEP within the U.S. populationwithin the U.S. population

24% (55 million) speak a non24% (55 million) speak a non--English language English language at homeat home

8.5% (24 million) have limited English 8.5% (24 million) have limited English proficiency (LEP)proficiency (LEP)

(Divi et al. (2007)

LEP and Patient SafetyLEP and Patient Safety

Adverse events affect LEP patients more Adverse events affect LEP patients more severely than English speaking (ESP) patientsseverely than English speaking (ESP) patients

Medical errors more likely due to communication Medical errors more likely due to communication problems for LEP vs ESP patients problems for LEP vs ESP patients

LEP patients more likely to suffer from physical LEP patients more likely to suffer from physical harm when errors occurharm when errors occur

(Divi et al., 2007)

Most medical interpretation errors have potential Most medical interpretation errors have potential clinical consequencesclinical consequences

Errors in medical interpretation less common Errors in medical interpretation less common with trained than adwith trained than ad--hoc interpretershoc interpreters

LEP patients are often managed without a LEP patients are often managed without a professional interpreterprofessional interpreter

(Flores et al., 2002, 2003; Flores 2005; Diamond et al., 2009)

Project GoalsProject GoalsDevelop, test, and implement:Develop, test, and implement:

•• New TeamSTEPPS training module, teaching team behaviors New TeamSTEPPS training module, teaching team behaviors to improve safety in LEP and culturally diverse patient to improve safety in LEP and culturally diverse patient populationspopulations

•• Hospital Guide on preventing, identifying, and reporting medicalHospital Guide on preventing, identifying, and reporting medical errors due to language barriers and crosserrors due to language barriers and cross--cultural cultural communication problemscommunication problems

Preliminary Research QuestionsPreliminary Research Questions

What is theWhat is the Role Role of Language Barriers and Cultural of Language Barriers and Cultural Discordance in Patient Safety Events affecting LEP Discordance in Patient Safety Events affecting LEP Patients?Patients?

How are Hospitals Addressing Linguistic and CulturalHow are Hospitals Addressing Linguistic and CulturalSources Sources ofof ErrorError??

1.1. Adverse Events DataAdverse Events Data2.2. Interpreter Pilot Interpreter Pilot 3.3. Town Hall Town Hall 4.4. Qualitative InterviewsQualitative Interviews

Data SourcesData Sources

Key FindingsKey Findings

Common Causes of Medical Errors for Common Causes of Medical Errors for LEP PatientsLEP Patients

1.1. Use of nonUse of non--qualified interpretersqualified interpreters

2.2. Use of family members/friends or house staffUse of family members/friends or house staff

3.3. Providers Providers ““getting bygetting by”” with basic language with basic language skillsskills

4.4. Cultural beliefs/values impacting patient careCultural beliefs/values impacting patient care

““In French, estomac is the stomach, but in Creole, lestomak In French, estomac is the stomach, but in Creole, lestomak mwen means, mwen means, ““my chestmy chest””. Without an interpreter present, a . Without an interpreter present, a FrenchFrench--speaking provider could incorrectly think a patient speaking provider could incorrectly think a patient was experiencing stomach pain, not chest pain. This is a was experiencing stomach pain, not chest pain. This is a potentially lifepotentially life--threatening errorthreatening error”” (interpreter).(interpreter).

““The patient comes in, doesnThe patient comes in, doesn’’t speak the language, and t speak the language, and they donthey don’’t have the t have the ‘‘timetime’…’….or they don.or they don’’t wait enough t wait enough time to call the interpreter. They want to do it time to call the interpreter. They want to do it quickly...they grab anyone going through, like you know, quickly...they grab anyone going through, like you know, the cleaning lady orthe cleaning lady or……anyone who knows how to speak anyone who knows how to speak the language and help them to interpretthe language and help them to interpret”” (interpreter).(interpreter).

High Risk ScenariosHigh Risk Scenarios

Medication ReconciliationMedication ReconciliationPatient DischargePatient DischargeInformed Consent ProcessesInformed Consent ProcessesEmergency Department VisitsEmergency Department VisitsOther Departments w High RiskOther Departments w High Risk

Labor and DeliveryLabor and DeliveryPsychiatric UnitsPsychiatric Units

Other Scenarios Other Scenarios Mental health assessmentsMental health assessmentsPrimary care referralsPrimary care referralsProvision of specialty careProvision of specialty care

High Risk Scenarios: Medication High Risk Scenarios: Medication ReconciliationReconciliation

““After the whole assessment was done [in English], the After the whole assessment was done [in English], the patient answered inappropriatelypatient answered inappropriately……made the nurse made the nurse doubt. She called interpreters, and I arrived. She said, doubt. She called interpreters, and I arrived. She said, ‘‘I I only have one question. Why is the patient answering only have one question. Why is the patient answering that with anesthesiathat with anesthesia…’…’. At this point I am not clear. At this point I am not clear…….the .the nurse then asked again, nurse then asked again, ‘‘Are you allergicAre you allergic……you said you said youyou’’re not allergic to medicinere not allergic to medicine…….drug or latex.drug or latex’’ And when And when I interpreted, [the patient] said, I interpreted, [the patient] said, ““I am allergic to latexI am allergic to latex““ (interpreter). And if she hadn(interpreter). And if she hadn’’t answered that t answered that inappropriately, she would have gone to the OR with a inappropriately, she would have gone to the OR with a latex allergy latex allergy (interpreter).(interpreter).

High Risk Scenarios: Patient DischargeHigh Risk Scenarios: Patient Discharge

““I try to say, I try to say, ‘‘The interpreterThe interpreter’’s coming.s coming.’’ I try to stall. But I I try to stall. But I can honestly say, there have been times when Ican honestly say, there have been times when I’’ve been ve been kind of pushed (kind of pushed (…… ) And it) And it’’s hard when somebodys hard when somebody’’s s pushing and saying, pushing and saying, ‘‘I have to go. My family member has I have to go. My family member has been here waiting with me for the interpreterbeen here waiting with me for the interpreter…’…’ (nurse).(nurse).

Maybe somebody else requires that bed. So thatMaybe somebody else requires that bed. So that’’s when s when we do our discharge. I would like to see the doctorwe do our discharge. I would like to see the doctor’’s face s face if I go over there, and say, if I go over there, and say, ““you know, I really canyou know, I really can’’t t discharge this patient because he doesndischarge this patient because he doesn’’t really t really understand anythingunderstand anything”” (nurse).(nurse).

Role of Behaviors & CommunicationRole of Behaviors & Communication

Failure to identify patient language needs in a Failure to identify patient language needs in a timely mannertimely manner

Failure to get an interpreter (or the right Failure to get an interpreter (or the right interpreter) to the encounterinterpreter) to the encounter

Failure to fully integrate the interpreter into the Failure to fully integrate the interpreter into the patient safety teampatient safety team

Failure to address interpreter shortagesFailure to address interpreter shortages

““The role of the interpreter is what we call black box. The role of the interpreter is what we call black box. The roleThe role……is to render the words onlyis to render the words only”” (patient safety (patient safety leader).leader).

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

Failure to Integrate Interpreter into Failure to Integrate Interpreter into Patient Safety TeamPatient Safety Team

Hospital Efforts to Address Linguistic Hospital Efforts to Address Linguistic and Cultural Sources of Errorand Cultural Sources of Error

Language data collection Language data collection –– Not systematic or Not systematic or routineroutine

Safety reporting systems Safety reporting systems –– No field for language No field for language or interpreter roleor interpreter role

Medical error monitoring Medical error monitoring –– No routine monitoring No routine monitoring for LEPfor LEP

TeamSTEPPS TrainingTeamSTEPPS Training

TeamSTEPPSTeamSTEPPS

Teamwork system to improve patient Teamwork system to improve patient safetysafety

Rooted in 20 years of research on teamworkRooted in 20 years of research on teamwork

Helps persons of lower hierarchical status Helps persons of lower hierarchical status communicate about patient safety riskscommunicate about patient safety risks

Teaches persons of higher hierarchical Teaches persons of higher hierarchical status to better respondstatus to better respond

AudienceAudience

Trainers for each participating hospitalTrainers for each participating hospitalTrainees: Interprofessional care team in a Trainees: Interprofessional care team in a hospital unithospital unit

DoctorsDoctorsNursesNursesTechniciansTechniciansFront desk staffFront desk staffInterpretersInterpreters

Learning GoalsLearning Goals

Understand safety risks to LEP patientsUnderstand safety risks to LEP patients

Assemble the right team for LEP patientsAssemble the right team for LEP patients

Identify and raise patient communication issuesIdentify and raise patient communication issues

Module ComponentsModule Components

Powerpoint presentationPowerpoint presentation

Video vignettesVideo vignettes

ExercisesExercises

5050--60 minutes total60 minutes total

Sneak peek: Process MapSneak peek: Process Map

Stop the Line: CUSStop the Line: CUS

(insert video clip of CUS here)(insert video clip of CUS here)

Creating psychological safetyCreating psychological safety

Proactively invite input Proactively invite input

Ask for mutual supportAsk for mutual support

Be accessibleBe accessible

Team leader: Team leader: ““If you see anything that seems risky or that the If you see anything that seems risky or that the patient doesnpatient doesn’’t understand, please speak upt understand, please speak up””

Interpreter: Interpreter: ““If you see anything that seems risky or you donIf you see anything that seems risky or you don’’t t understand please speak up. I will help youunderstand please speak up. I will help you””

Sample VideoSample Video

Hospital Guide Hospital Guide

AudienceAudience

Hospital LeadersHospital LeadersQualityQualityPatient SafetyPatient SafetyInterpreter ServicesInterpreter Services

ObjectivesObjectives

Present evidence on medical errors due to language and Present evidence on medical errors due to language and cultural barriers among LEP patientscultural barriers among LEP patients

Present strategies and training tools to create systems Present strategies and training tools to create systems and an organizational culture to improve LEP patient and an organizational culture to improve LEP patient safety in a variety of hospital settings safety in a variety of hospital settings

Create a set of case examples that solidify learningCreate a set of case examples that solidify learning

Provide resources which can be useful in developing a Provide resources which can be useful in developing a robust LEP patient error reporting and response system robust LEP patient error reporting and response system

OutlineOutline

1.1. Making the case for LEP and patient safetyMaking the case for LEP and patient safety

2.2. Why should you care?Why should you care?

3.3. Laying the foundation to reduce medical errors Laying the foundation to reduce medical errors among LEP and culturally diverse patientsamong LEP and culturally diverse patients

4.4. Developing systems ready for prime timeDeveloping systems ready for prime time

5.5. Utilizing structured communication tools & Utilizing structured communication tools & TeamSTEPPS approachTeamSTEPPS approach

6.6. Responding to medical errors: identifying, Responding to medical errors: identifying, reporting, and addressing medical errorsreporting, and addressing medical errors

7.7. Resources and tools to address language and Resources and tools to address language and cultural barriers and to improve patient safetycultural barriers and to improve patient safety

StrategiesStrategiesIncorporate interpreters formally into care team:Incorporate interpreters formally into care team:

conduct regular rounds to check on LEP patientsconduct regular rounds to check on LEP patientsbe included in and present at rounds for complicated LEP patientbe included in and present at rounds for complicated LEP patientss

OnOn--going training in patient safety, cultural competency, and going training in patient safety, cultural competency, and utilization of interpreters utilization of interpreters Identify patientsIdentify patients’’ language needs on boards in inlanguage needs on boards in in--patient wardspatient wards““Interpreter requested cardInterpreter requested card”” and/or language identification braceletsand/or language identification braceletsCreate waiver form for patients who refuse interpreter services Create waiver form for patients who refuse interpreter services Develop better processes for translating materialsDevelop better processes for translating materialsQuality and Safety:Quality and Safety:

Executive members conduct rounds with interpretersExecutive members conduct rounds with interpretersMonitoring forms should include check boxes for languageMonitoring forms should include check boxes for language

Policy IssuesPolicy Issues

Reimbursement policies interpreter Reimbursement policies interpreter shortagesshortages

Professional standards unclear on how to Professional standards unclear on how to handle interpreter role conflicts handle interpreter role conflicts (interpretation, cultural brokerage, (interpretation, cultural brokerage, advocacy) advocacy)

Advocate to correct mistreatment or abuseAdvocate to correct mistreatment or abuse

SummarySummary

An emerging body of evidence has identified a An emerging body of evidence has identified a link between LEP and medical errors link between LEP and medical errors

Trained interpreters are key to reduce medical Trained interpreters are key to reduce medical errors for LEP patientserrors for LEP patients

Team training can helpTeam training can helpTeamSTEPPS ModuleTeamSTEPPS ModuleOngoing training in patient safety, cultural Ongoing training in patient safety, cultural competency, and how to utilize interpreterscompetency, and how to utilize interpreters

Hospital leaders can play a major role in building Hospital leaders can play a major role in building safety systems with attention to LEP issues safety systems with attention to LEP issues

The new Hospital Guide and TeamSTEPPS The new Hospital Guide and TeamSTEPPS Training Module will advance work in this areaTraining Module will advance work in this area

Full effect requires highFull effect requires high--level policy changeslevel policy changes