Families of Limited English Proficiency (LEP) patients admitted to our children's hospital inpatient units do not consistently receive daily updates from the medical team using qualified interpreter services despite widespread availability of in-person interpreters, over the phone interpreting services (OPI), and video remote interpreting services (VRI). Inadequate knowledge regarding best practice for language interpreter use by providers, time constraints, and lack of available resources were some of the enterprise-wide identified problems. In addition, physician documentation of interpreter use is inconsistent because of absence of a standard practice.
Baseline data collected over 6 weeks from all the pediatric inpatient nursing units revealed that a median of 43% of LEP families surveyed reported that an official language interpreter service was used to update them regarding their child's daily care plan. Among those, median documentation of interpreter services in the daily progress note was 0%. This was far from optimal per the Civil Rights Act, Institutional Policy, and Joint Commission Policy.1–3
According to the 2018 United States Census Bureau and Center for Immigration Studies, about 67 million individuals spoke a language other than English.4,5 Of those, 42% were considered LEP (anyone above the age of five who reported speaking English less than “very well”). Section 1557 of the Affordable Care Act, a Department of Human and Health Services (DHHS) law (Title VI of the Civil Rights Act of 1964), prohibits discrimination of healthcare based on nationality, race, color, age, sex, or disability.2,3 This law requires any health program or activity with funding from the DHHS to ensure that LEP individuals receive language assistance via a qualified interpreter, whose competencies must include: proficiency in medical terminology in the language, understanding medical ethics, and the ability to accurately interpret in the language.2,3 Section 1557 prohibits using family, friends, or unqualified bilingual physician, coined “ad hoc interpreters.”6 Multilingual hospital physicians are not deemed qualified interpreters based solely on their language fluency.7–9 The Joint Commission (JC) has set competency requirements with language proficiency assessments, education, training, and experience, which varies among institutions, for multilingual hospital physicians to serve as interpreters.1
Although access to language services is a priority for healthcare institutions, delivery of these services is variable.6,10,11 Among others, the gap in education of best-practices and availability of services to new trainees and staff remains a barrier for optimal use of interpreters.12–14 Our healthcare institution serves patients from all over the world prioritizing unique needs and cultures while delivering healthcare. Global Patient Services (GPS) is a comprehensive team within our institution that supports international patients throughout their treatment journey including scheduling appointments, facilitating transportation, language interpretation, and transitioning care. Per our GPS annual compliance policy, multilingual physicians can communicate with their patients in their preferred language. However, to serve as a qualified interpreter, the physician needs to meet certain competency requirements, including a 40-hour training course.
Literature reveals that LEP patients who do not receive interpretative services are at greater risk of compromised patient care quality and serious adverse events including diagnostic and medication errors.6,7,10,15 This in conjunction with the legal mandate, makes the use of official language interpreters for LEP patients an absolute necessity.8,11 There is also association with lower compliance with follow-up appointments, decreased patient satisfaction, prolonged hospital stays, lack of appropriate informed consent and increased readmission rates among LEP patients.11,16 On the contrary, LEP patients who received interpretative services have overall improved care with less errors in communication, better medical outcomes, and increased patient satisfaction.6,16
Despite being readily available, these services are often underutilized.6,10–12,17,18 A quality improvement (QI) study conducted at a children's hospital improved interpretative service use through educating healthcare providers on the use of the telephone interpretative services, providing widespread reminders, and ensuring dual-headset phones in every room.19, 20
Given the importance of medical interpreter services for equitable and safe healthcare distribution for LEP patients as demonstrated in the literature and the gap in performance identified in our clinical practice, it is imperative to optimize practices via QI methodology.
We aimed to increase daily use of official interpreters for LEP families on our pediatric inpatient units from a baseline of 43% to 65% within 3 months. We also aimed to increase physician documentation of interpreter use from a baseline of 0% to 55% within 3 months.
The study was conducted at a tertiary Children's Hospital comprising 120 inpatient pediatric beds, serving as a transplant center with a GPS department to coordinate needs of international patients. Our QI team consisted of pediatric residents, nurse managers, pediatric inpatient physicians, and a GPS representative. This study was conducted on five inpatient pediatric units which were similar in size and acuity, excluding intensive care units. Patients were admitted to multiple inpatient pediatric services, including hospital medicine, nephrology, gastroenterology, pulmonology, cardiology, hematology/oncology, endocrinology, bone marrow transplant (BMT), epilepsy, surgery, otolaryngology, and orthopedics.
Interpreter services are readily available, including in-person interpreter for the four most spoken languages (Arabic, Spanish, Nepali, Russian), in addition to Cyracom OPI and VRI for 20 languages (see Appendix 1, Supplemental Digital Content 1, https://links.lww.com/JHQ/A167), which can be used via an iPad, a dual head-set phone, or by calling a number from a cell phone or landline.
This is a prospective quality improvement study design, and the methodology adapted was based on the Model for Improvement with use of multiple plan-do-study-act (PDSA) cycles to test individual interventions over time for measurable change.20
On admission, nursing staff obtain information including preferred language from the legal guardian of each patient, which is then entered into the electronic medical record (EMR) and visible to all care teams. This was used to determine LEP families on the pediatric inpatient units. A written two-question survey was created and distributed among LEP families to determine need for interpreter service use and whether an official interpreter service was used to update them regarding their child's care at least once daily. The survey was created in English and translated to the four most spoken languages using official translation services provided by GPS (see Appendix 2-6, Supplemental Digital Content, https://links.lww.com/JHQ/A168, https://links.lww.com/JHQ/A169, https://links.lww.com/JHQ/A170, https://links.lww.com/JHQ/A171, https://links.lww.com/JHQ/A172). If the LEP family spoke a language not among the four, official interpreter service was used to verbally administer the survey and obtain data in a confidential manner by two members of the study team not directly involved in their medical care. A pilot for this survey was initially administered to LEP patients on the pediatric hematology/oncology and BMT inpatient unit for a 1-week period. The survey was then modified for clarity based on patient feedback.
Surveys were distributed every Monday–Thursday for a baseline data collection period of 6 weeks from April to June 2020, followed by 12 weeks of data collection during and after interventions from June to August 2020. During distribution of the survey, the purpose of the project was explained to LEP families. LEP families were informed that participation was voluntary and anonymous, and that refusal would not affect the quality of medical care. The final survey was then distributed to parents of every LEP patient admitted to all five inpatient pediatric units. Given the limited number of LEP patients and their distribution across all inpatient units, interventions were initiated in all included units, rather than a single unit pilot test.
After baseline data collection, a cause-and-effect diagram was constructed through discussions with involved stakeholders including nursing, GPS, physicians, residents, and LEP patients' families (on a voluntary basis) to understand current conditions and identify root causes of the problem (Figure 1). The root cause analysis identified the major issues to be inadequate knowledge regarding policy around interpreter service use, lack of awareness of logistics and challenges in using interpreter services, lack of readily available equipment, time constraints, ease of “ad hoc” interpreter use, absence of an established standardized documentation process, lack of patient-empowerment, and patient concern of the service being an extra cost.
A 6-week baseline data collection was performed before interventions which identified 91 LEP patients. Among them, 45% (n = 41/91) reported official language interpreter use; median 43% (Figure 2) and 10% (n = 9/91) had daily clinical documentation of interpreter service use; median 0% (Figure 3). After this, four intervention periods or PDSA cycles were implemented, comprising of multiple parts. The initial intervention period was crafted based on the main problems identified during the root cause analysis with subsequent interventions based on thorough review of project measures to ensure sustained change.
- Intervention period one during Weeks 7 and 8:
Intervention Period 2, 2-part during Week 9:
- - Coordination with the nurse managers to ensure placement of dual head-set phone in every LEP patient room on admission and nurses were empowered to encourage interpreter service use on daily rounds.
- - Electronic communication was sent to all pediatric physicians, fellows, and residents detailing institutional policy and importance of using interpreter services, their availability and logistics, and the importance of documenting interpreter service use.
- - Visual display and flyers with logistics were placed in the resident working area to reinforce best practices (see Appendix 7, Supplemental Digital Content, https://links.lww.com/JHQ/A173).
Intervention period 3 during Week 10:
- - Part one involved development of Informative flyers (see Appendix 1, Supplemental Digital Content, https://links.lww.com/JHQ/A167) which were provided directly to LEP patients on admission along with dual-set headphone and distribution of visual displays and flyers (originally placed in resident work areas during intervention Period #1) to all inpatient rooms and nursing stations to remind providers and empower families (see Appendix 7, Supplemental Digital Content, https://links.lww.com/JHQ/A173).
- - The second part comprised of standardization documentation of interpreter use. A dot phrase, which is a shortcut that inserts preformed text, was created in the EMR for documentation with reminder tabs placed in all workstation computers to encourage use (see Appendix 8, Supplemental Digital Content, https://links.lww.com/JHQ/A174).
Intervention period 4 during Weeks 11–18:
- - Education of residents regarding incorporation of a language column to the EMR patient list for easy identification of patients' preferred language. In addition, the patients' preferred language was added to daily resident sign-out with instructions on how to update the same. A follow-up email was sent to physicians, fellows, and residents about the project, highlighting the importance of documentation using the dot phrase.
- - The focus was on re-education and reinforcement. Best practices were electronically communicated with the BMT service nurse practitioners after identification of a major LEP patient population on this non–resident-driven specialty service.
- - A guide for language column use was created and distributed to residents and to physicians. New interns/trainees were provided contact details regarding interpreter use.
- - Finally, a formal educational conference was held detailing the entire project and reinforcing best practices.
Our outcome measures included: (1) percentage of weekly LEP patients who received appropriate interpreter service as self-reported by LEP families, and (2) percentage of interpreter service use documented in the progress note per week.
Constant evaluation was underway using process, outcome, and balancing measures over the course of interventions. The process measures entailed identification of LEP patients through introduction of language column in EMR and later in the hospital-wide sign-out system, timely administration of surveys to LEP patient families without interruption of workflow, availability of dual headset-phones in patient rooms, and nursing advocacy. Documentation of interpreter use for LEP patients was tracked daily through the EMR. Balance measures included ensuring smooth workflow for nursing, lack of disruption to rounds with use of virtual or in-person official interpreters and modification of the dot-phrase for ease of documentation. This was achieved through meetings with the nursing managers for feedback prior to and during the interventions to ensure that nursing workflow was not adversely affected. Frequent communication was maintained with the residents and physicians on hospital service to ensure a smooth rounding process along with reminders regarding best practices surrounding interpreter services. During collection of surveys, informal check-ins were conducted with LEP patients to identify satisfaction from a patient perspective.
De-identified data were collected for a total 18 weeks, including the 6-week baseline data period revealed a total of 239 LEP patients. Chart review was performed based on survey responses to ascertain whether documentation was appropriate. Survey responses and documentation were tracked in a confidential manner throughout the course of the project. Data analyses were performed weekly and at the end of each PDSA cycle with comparison to the goal after development of a baseline median. Measures described above were tracked and reported weekly. After baseline data collection, the first PDSA cycle was initiated with extensive review of project measures with stakeholders and team members, which led to the development of specific interventions that were implemented during the next cycle to ensure sustained change. After every intervention period the run chart was used to examine changes in our outcomes.
Six or more consecutive data points above the median was considered a shift. Other elements of the data, including details of breakdown by team were interpreted using percentages.
The institutional review board (IRB) determined this project involves an internal quality assessment and QI that is part of standard healthcare operations in the local setting rather than research and waived the requirement for IRB approval.
Over the 12-week study period, a total of 148 LEP patients were identified across all units. The most common language was Arabic (83%) followed by Spanish (8%). Among identified LEP patients, 45% were on the pediatric BMT service (n = 105), 15% on hematology/oncology (n = 37), 14% on gastroenterology (n = 34), 13% on hospital medicine (n = 32), 10% on cardiology (n = 25), 2% on epilepsy (n = 4), and 1% on surgery (n = 2). The primary medical service remained independent of their location or interventions.
An average of 66% (median 73%) LEP patient families reported official interpreter use over the course of the study (Figure 2). Among these, 57% (median 59%) had daily progress note documentation of interpreter use (Figure 3). After 1 week of Intervention 3, there was marked improvement in official interpreter use to 85% (n = 11/13), which was then sustained at an average of 73.7% (n = 61/83) after Intervention 4.
There was no reported workflow disruption from nursing or physician teams over the course of the interventions. The standardized documentation process did not increase clinical documentation time for the healthcare teams.
Despite being an essential standard of care in accordance with legal obligations, and our institutional policy,1–3 our baseline data collection revealed that official interpreter service use was suboptimal, with inconsistent documentation.
This project successfully led to increased patient-reported use of official interpreter services and improved documentation through targeted multifaceted interventions such as extensive education of best practices for healthcare providers, ensuring ease of access of interpreter services, standardizing documentation, and empowering LEP patients. A shift in the data as it relates to interpreter use and documentation was identified, signaling special cause variation as a direct temporal effect of Intervention 2. Visual flyers, patient-specific bundles, further education, reinforcement, and posted reminders regarding documentation practices helped sustain the newly established practices (refer Figures 2 and 3). This sustainability was also made possible with an overall improvement in communication between GPS and the healthcare team as a direct result of our interventions. At Week 10 of intervention Period 3, a disparity was identified for documentation among BMT patients which improved targeted towards best practices education of mid-level BMT providers. Buy-in and frequent feedback from stakeholders was instrumental to sustainability of the interventions. Some of the challenges addressed include need for constant education, communication and reinforcement of best practices pertaining to interpreter use because of frequent change in schedules of the members comprising the patient care team, in addition to influx of new providers and nurses. This initiative was integral to empowering team members and patients to encourage interpreter use to ensure equity in distribution of care with improved healthcare outcomes.
There were many limitations to our study. A limitation stemmed from prolonged hospital course for some LEP patients leading to inaccurate survey responses by the family. The answer “no” was not necessarily indicative of a lack of interpreter use that day, but rather may have been reflective of lack of changes to the care plan or absence of new medical issues other than the ones previously identified.
Another limitation was the lack of data obtained from Friday–Sunday because of varying clinical responsibilities of the authors. Therefore, compliance during these days was not assessed. No data were obtained on interpreter services refusal by families, refusal to participate in the survey, length of hospital stay, compliance with processes implemented, analysis of interventions, and staff satisfaction.
Other limitations of this study stemmed from restrictions to international travel during the onset of the COVID-19 pandemic, reducing the volume of hospitalized international LEP patients.
Technical issues regarding the availability of interpreter services such as difficulty connecting to an interpreter, and a lack of readily available official interpreters in rarely used languages such as Hebrew or Yiddish, was another limitation.
The availability of official interpreter services is a requirement by law and its use is essential to standard medical care for LEP patients with clear benefits and improved healthcare use.6,16 Our study highlights a special cause variation with improved official interpreter use and documentation as a direct result of interventions. The interventions incorporated a family-centered approach surrounding processes and protocols to ensure high-quality, equitable care. Overall, our study highlights easily reproducible, successful interventions which can be extended to other areas and across institutions. Despite improved interpreter services from baseline, this expected standard of care remains suboptimal with a wide gap between cultural awareness and need for standardized practices for official interpreter services. Ongoing multidisciplinary education and cooperation is required to promote equitable distribution of safe healthcare practices in a timely manner.
Future direction includes widespread implementation of similar interventions to other pediatric units, including intensive care units, outpatient settings, and across the institution. In addition, future studies are needed to assess the long-term outcomes of official language interpreter use including readmission rates, healthcare literacy, and reduction of adverse events related specifically to language barriers. Further studies in this field can help identify barriers and facilitators and sustainable interventions to enhance documentation and use of this essential service by healthcare personnel.
Mohga Behairy, DO, conceptualized the project, developed and designed the project, recruited team members and stakeholders, created the data collection surveys, collected data, conceptualized and created interventions, implemented interventions, analyzed data, drafted the initial manuscript, and reviewed and revised the manuscript.
Amala Alenchery, MD, designed the project, collected data, conceptualized and created interventions, implemented interventions, analyzed data, drafted the initial manuscript, and reviewed and revised the manuscript.
Claudia Cuesta-Ferrino collaborated in the translations of survey materials, provided information and detailed guidelines of various interpreting services, and revised the manuscript.
Hemangini Bhakta, MD, conceptualized and supervised the project, created the data collection surveys, conceptualized interventions, and critically reviewed the manuscript for important intellectual content.
Arnaldo Zayas-Santiago, MD, conceptualized and supervised the project, created the data collection surveys, conceptualized interventions, and critically reviewed the manuscript for important intellectual content.
The authors would like to thank the following people for their contribution to the success of the project: Global Patient Services, nurse managers, nurses, pediatric residents and fellows, advanced practice nurses, and attending providers.
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