Improving Patient Safety Systems for Patients With Limited English Proficiency

A Guide for Hospitals

Research suggests that adverse events affect patients with limited English proficiency (LEP) more frequently, are often caused by communication problems, and are more likely to result in serious harm compared to those that affect English-speaking patients. This guide focuses on how hospitals can better identify, report, monitor, and prevent medical errors in patients with LEP.

Prepared by: The Disparities Solutions Center, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA and Abt Associates, Cambridge, MA under Contract No. HHSA290200600011I.

The authors of this guide are responsible for its content. The opinions expressed in this document are those of the authors and do not reflect the official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. Statements in the guide should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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Contents

Acknowledgments
Foreword
About This Guide
   Goal of the Hospital Guide
   Target Audience
   Organization of the Guide
Executive Summary
   What We Know About Safety and Limited English Proficiency
   Why Focus on LEP and Patient Safety?
   Common Causes of Adverse Events for LEP and Culturally Diverse Patients
   Systems and Strategies To Improve Safety for LEP Patients
   Specific Recommendations for High-Risk Scenarios
   Improving Team Communication To Foster Safety for LEP Patients: TeamSTEPPS® LEP Module
   Frequently Asked Questions (FAQs)
Chapter 1: Background on Patient Safety and LEP Populations
   What We Know About Safety and Limited-English-Proficient Patients
   What We Know About Hospitals' Response to LEP Patient Safety
   Why Hospitals Should Focus on Patient Safety for LEP Populations
   Common Causes of Adverse Events for LEP and Culturally Diverse Patients
   High-Risk Scenarios
Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients
   Foster a Supportive Culture for Safety of Diverse Patient Populations
   Adapt Current Systems To Better Identify Medical Errors Among Patients with LEP
   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
Chapter 3: Improving Team Communication To Foster Safety for LEP Patients: TeamSTEPPS LEP Module
   Background on TeamSTEPPS and the TeamSTEPPS LEP Module
   TeamSTEPPS Module Content: Team Behaviors To Improve LEP Patient Safety
   Summary of TeamSTEPPS LEP Module
References
Appendixes
Appendix A: Recommendations for Staff Training
Appendix B: Bringing It To Life - Case Study
Appendix C: Advisory Board Members
Appendix D: Methods
Appendix E: Resources and Tools To Address Language and Cultural Barriers and Improve Patient Safety
Appendix F: PowerPoint Presentation: Executive Summary

Acknowledgments

Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals is the product of collaboration between the Disparities Solutions Center, Mongan Institute for Health Policy at Massachusetts General Hospital, Abt Associates, and the U.S. Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ).

Many individuals contributed to the development of this guide, including hospital leaders and frontline staff who agreed to be interviewed as part of this project, as well as our Advisory Board. Their participation, expertise, and support have been a great help.

Specifically, we thank:

  • Cindy Brach, MPP, AHRQ.
  • Izabel Arocha, MEd, CMI, Executive Director of International Medical Interpreters Association.
  • Anabela Nunes, Manager of Interpreter Services at Massachusetts General Hospital.
  • Mark Spranca, PhD, Vice President in the Health Policy and Clinical Research Division of Abt Associates.
  • Laura Maynard, TeamSTEPPS® Master-Trainer and Director of Collaborative Learning at the North Carolina Hospital Association's Center for Hospital Quality and Patient Safety.
  • Aswita Tan-McGrory, MBA, MSPH, Deputy Director of the Disparities Solutions Center.
  • Marina Cervantes, Former Research Assistant at the Disparities Solutions Center.

No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this guide.

This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without specific permission of copyright holders.

Foreword

The landmark Institute of Medicine report To Err Is Human was an influential and transformative call to action, urging our health care system to ensure that patients not be harmed by care that is intended to help them. This led to a national effort in patient safety that was deep and broad and remains both a key pillar of quality and an essential aim of effective health care delivery. Although the principles of patient safety and the science of preventing medical errors have evolved and advanced over the years, recent evidence tells us that for minority patients and patients with limited English proficiency (LEP) we may be falling well short of our goals.

Research suggests that adverse events affect LEP patients more frequently, are often caused by communication problems, and are more likely to result in serious harm compared to those that affect English-speaking patients. Effective provider-patient communication is vital, especially in areas as critical as medication reconciliation, hospital discharge, informed consent, and surgical care (pre-, peri-, and post-op), to name a few. In fact, these communication-sensitive processes don't just put patients with LEP at risk. Patients with limited health literacy, those who may be affected by disabilities, and those who are subject to other vulnerabilities face an increased risk of misunderstanding and, in turn, medical errors.

The Joint Commission recently developed a new set of standards on Patient-Centered Communication that emphasize the importance of focusing on LEP, cultural competency, and patient-centered care in all aspects of quality. Starting this year, hospitals seeking accreditation will be expected to comply with these recommendations. As hospitals prepare for these standards and work to better ensure equity in patient safety, they will look for resources in this critical area of patient safety.

Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals and its companion TeamSTEPPS® LEP Training Module are two such resources—one focused on how hospitals can better identify, report, monitor, and prevent medical errors in patients with LEP; the other a training module that teaches a set of team behaviors and structured communication tools designed to reduce medical errors for LEP patients. Built on solid research and well-tested patient safety methodology, these tools provide the case for why this field is important, as well as the basic strategies necessary to build safety systems that truly protect all patients, especially the most vulnerable. The guide and TeamSTEPPS module are practical, actionable, and respectful of competing priorities. They provide a menu of activities to choose from that can immediately be integrated in a broader set of patient safety activities.

Recently the American Hospital Association stood with the Association of American Medical Colleges, American College of Healthcare Executives, Catholic Health Association of the United States, and National Association of Public Hospitals and Health Systems in a call to action to eliminate health care disparities. I'm hoping you will join me and other leaders across the country who are striving to meet the challenge of achieving equity and ensuring safe, high-quality care for all we serve and think that this guide will be an important tool for your organization in that journey.

Rich Umbdenstock
President and CEO
American Hospital Association

Current as of September 2012
Internet Citation: Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals. September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/lepguide/index.html