1. Loretta Saint-Louis, Ph.D. Cambridge Health Alliance IMIA October 2007 Improving Inpatient Language Access for Better, Patient-Centered Care: Partnering for Progress

2. 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

3. 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

4. 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

5. Cambridge Health Alliance 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

6. Linguistic Diversity at CHA 45% of patients have a primary language other than English 60+ languages in all, new languages arriving continuously Linguistically diverse work force Interpreter Services since 1970s Partnering for Progress

8. Interpreter Services Capacity 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

10. Haitian inpatient with pain A problem exposed Using the story to motivate change Applying for the grant Inpatient Interpreter Access: The Wake Up Call Partnering for Progress

11. 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

12. 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

13. Objectives of Project: Speaking Together Inpatient Work 1.Measurable quality improvement in clinical care for LEP patients Partnering for Progress

14. 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

15. Project Phases: Speaking Together 1.Become familiar with 7 measures Dec – Jan 06 2.Master data collectionFeb 06 – July 07 3.Quality ImprovementAug 07 – Feb 08 Partnering for Progress

16. Participants/Stakeholders Pathways Patients Interpreters Providers Nurses Staff Evaluation Risk Management Patient Relations Translation Coordinator Interpreter Managers Partnering for Progress

17. Participants/Stakeholders Pathways 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

18. Participants/Stakeholders Speaking Together 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

19. Pathways – Selecting the Pilot Unit 6 North at Cambridge Hospital Linguistic Diversity Nurse Manager engaged already in Quality Improvement Nurse Manager embraces cultural competency Partnering for Progress

20. Needs Assessment 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

21. 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

22. Linguistic Diversity at 6 North 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

23. Languages of Patients on 6 North Partnering for Progress

24. Linguistic Diversity of Staff 6N has 34 staff members 50% Staff bilingual/multilingual 33% of RNs, 80% of Nursing Assistants, 33% of Unit Secretaries Partnering for Progress

25. How did we improve the experience of our patients who speak other languages? Partnering for Progress

26. Welcome Letter to Patients & Interpreter Request Cards “Please call a medical interpreter so we can communicate better.” Partnering for Progress

27. Telephone Interpreting Equipment Dual handset and full duplex speaker phone capability at each bedside to facilitate telephone interpreting. Partnering for Progress

28. “You have a right to a medical interpreter at no cost to you.” 30 Language DPH Poster Partnering for Progress

29. Translated Materials Patient Education Materials clearly visible for nursing staff and providers. Several additional materials were translated. Partnering for Progress

30. Translated Materials Accessible to Patients Patient Materials and brochures also available in hallway for patients and family access. Partnering for Progress

31. How did we raise the awareness and what user-friendly tools did we provide for staff? Partnering for Progress

32. 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

33. Portuguese Arabic Vietnamese Chinese Italian Russian Haitian Spanish Hospital Phrase Booklets Partnering for Progress

34. Locator Board Language Magnets Language magnets easily identify patients that require interpreter assistance. Partnering for Progress

35. Communication to Staff Provider Board 6N Newsletter Emails Staff meetings CHA eBeat Partnering for Progress

36. 2 in-services for interpreters (day & night) 2 in-services for 6N staff (day & night) Follow up meetings with interpreters In-services for 6N and for Interpreters Partnering for Progress

37. Best situations for phone interpreting: For quick, focused conversation Patient-initiated conversation/comfort issue ADLs, When the matter is logistical or simple to explain Best situations for face-to-face interpreting: For serious or bad news For encounters that involve family discussion For patient education For confused or hard of hearing patients Guidelines (phone vs. face-to-face) Partnering for Progress

38. 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. Bilingual Staff Proficiency Testing Partnering for Progress

39. 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. Interactive program that provided pretest, education, three patient encounters, and a post test. Several providers completed the Quality Interactions Online Physician Module. Cultural Competency Training Partnering for Progress

40. Office of Minority Health best practices Introduce patient to interpreter services and teach them how to access interpreters Daily check in with patient about communication needs Identify individualized linguistic needs and collaborate with nursing staff Inpatient Interpreter Rounds Empower Patients Partnering for Progress

41. Point person for co-workers in addressing cultural and linguistic issues Helps ensure that their department meets the cultural and linguistic needs of patients. Works with their cultural supporter, Multilingual Interpreting, and others to implement improvements. Cultural Ambassador at 6 North Partnering for Progress

42. Challenges for Interpreter Service Limited staff (timeliness and access) Simultaneous demands of all departments & sites Inpatient needs seen as less time sensitive than ambulatory and emergency departments Logistics of covering interpreter rounds Evening, overnight, and weekend coverage Partnering for Progress

43. 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

44. 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 Evaluation of Pilot Partnering for Progress

45. Periodic patient interviews (n=4) 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

46. 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 Online provider/staff surveys (n=18) Partnering for Progress

47. 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 Online interpreter surveys (n=28) Partnering for Progress

48. 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 Medical Record Audits Partnering for Progress

49. 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 BCBS Results Partnering for Progress

50. 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 Lessons Learned Partnering for Progress

51. 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 Speaking Together Steps Partnering for Progress

52. 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 Speaking Together: Operations and Clinical Care www.speakingtogether.org Partnering for Progress

53. 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 Speaking Together National Measure ST2 Partnering for Progress

54. Data: interpreter encounter database with coded assessment and discharge encounters, medical records, Meditech, Language testing records of providers Sources of data for ST2 Partnering for Progress

56. 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 Results on ST2: Most inpatients not getting qualified language service for both assessment and discharge Partnering for Progress

57. 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 Next steps Partnering for Progress

58. 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! More Lessons Learned Partnering for Progress

59. 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! Thanks Partnering for Progress