Improving Patient Safety Systems for Patients With Limited English Proficiency
Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients
Hospitals of all types can engage in a systematic approach to better identify and prevent medical errors and adverse events that occur commonly among LEP patients. This chapter contains five key recommendations to improve detection of medical errors across diverse LEP populations and prevent high-risk scenarios from becoming safety events. Resources and tools from the TeamSTEPPS® LEP Module, which is further described in Chapter 3, are also highlighted throughout this chapter.
As with any organizational change, some activities build on current capacities and are easier to implement, while others might require more time, effort, and resources. Hospital quality and safety leaders have many opportunities to meet their obligation to build a patient safety system that takes the issues of LEP and patient diversity into account.
The following chapter will provide an overview (Figure 7) of the following strategies:
- 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.
Figure 7: Fostering a Supportive Culture for Safety of Diverse Patient Populations
We will then provide specific guidance on how to address the high-risk scenarios we have defined previously.
The recommendations provided here represent the ideal situation in which these issues can be addressed. We understand that hospitals may have resource or other limitations that preclude a full rollout of these strategies all at once. Therefore, we recommend that hospitals with resource or other limitations begin incrementally by choosing any strategies that can be readily implemented and, at a minimum, focus on addressing the root causes that lead to high-risk scenarios for medical errors among LEP patients.
Foster a Supportive Culture for Safety of Diverse Patient Populations
Patient safety requires an organizational culture that supports identifying, reporting, and discussing near misses and medical errors, as well as developing strategies to prevent them. Leadership must communicate the importance of a just culture, where a balance is maintained between a blame-free approach to facilitate a focus on systems and accountability for reckless behavior.48, 49 Leadership must also communicate the importance of a blame-free environment and the need to learn from mistakes to improve quality of care.
Although creating this environment can be challenging, evidence has shown it has been accomplished more generally by many hospitals across the Nation.50 However, our research reveals that little attention has focused on creating a culture that supports safety for diverse populations in particular, including LEP patients. Systems for identifying, reporting, and monitoring errors across diverse populations, and strategies to address the root causes of these errors, are few and far between and rarely if ever include a focus on leadership. The institutional culture needed to support work in this area has not been created but remains essential if efforts in this area are to succeed.
Our research revealed several key areas for improvement to ensure that addressing issues of LEP and culturally diverse patients is seen as an essential part of the safety culture:
- Support from leadership is currently absent but required.
- Institutional buy-in must be achieved within the organization and the message must get on the staff's radar-screen, as it is not there now.
- A set of policies and strategies is needed to support individuals' work and to ensure that the tools and processes are in place for them to succeed. These are largely missing today.
- Although historically physicians have shied away from discussing errors with patients, when done properly, disclosure can create a culture of safety and reduce the likelihood of a lawsuit.
Foster a supportive culture for safety of diverse patient populations, articulated clearly by leadership, operationalized in strategic planning for the organization, and supported by providing staff with the key tools and resources to accomplish this goal.
- Assess the current safety climate51-54 and interweave language and cultural barriers into the overall message and mission of the culture of quality and safety. Frame messaging within the existing efforts and standards related to quality and safety for all patients.
- Share lessons learned from patient safety events with all staff to help build an institutional culture sensitive to issues that affect LEP patients; and ensure ongoing learning and training in this area. Involve patients in family advisory councils or cultural advisory groups to incorporate patient perspectives.
- Include the goal of improving care and patient safety for LEP patients within the organization's operating plan. Recognize leadership's role in supporting staff to better care for LEP patients and families by building expectations into staff training, new employee orientations, and performance management systems.
- Develop collaborations between quality and safety departments and interpreter service departments to help align the message among diverse staff. These types of collaborations (e.g., training forums, information sessions, patient rounds) and messaging can also help dispel the power dynamics between staff, interpreters, and physicians that deter the reporting process.
- Ensure that clinicians communicate effectively about errors with patients and their families.55-57 Clinicians should receive training on guidelines for disclosing medical errors to patients,58 specifically for LEP patients when additional factors (e.g., language and cultural beliefs) may affect the discussion.
|The TeamSTEPPS LEP Module provides hospitals with tools to assess organizational readiness and provides all staff with communication skills that help build a supportive culture of safety for LEP patients.|
Adapt Current Systems To Better Identify Medical Errors Among LEP Patients
To accurately identify and analyze medical errors that occur due to language barriers and cultural differences, data on race, ethnicity, language preference, and English proficiency must be collected routinely on all patients.59 This task may be especially difficult in pediatric settings where race, ethnicity, and language preference data are collected on the parent or caregiver as well as the patient. Without this information (ideally collected at patient registration), hospitals are limited in their ability to address high-risk scenarios that may prevent safety events among LEP patients.
Our research revealed several key areas that need improvement to ensure that patient safety systems are able to identify medical errors among LEP and culturally diverse patients.
- The current capacity to identify medical errors in LEP patients is severely limited by the lack of systematic collection of race, ethnicity, and language preference (REL) and English proficiency data across the country. This data collection is absolutely necessary.
- Even when REL data are collected, they are rarely linked to the patient safety reporting system. Creating these links would facilitate identification of errors involving LEP patients.
- The role of cultural values and beliefs may also be an important component in patient safety issues affecting LEP and culturally diverse patients. However, current patient safety systems in hospitals are not tailored to capture the specific contributing factors that may compromise care for LEP patients. Capturing this key information is essential to the care of diverse populations.
|The TeamSTEPPS LEP Module encourages frontline staff to collect REL data early in the care process and encourages hospitals to document REL and cultural factors in patient safety reporting systems.|
Adapt current systems to better identify medical errors in LEP patients by collecting patients' REL data at registration, improving the capacity of patient safety systems to capture key root causes and risk factors for LEP patients, and linking these databases so that this information is readily accessible.
- Collect REL data systematically at registration, early in the care process (go to Figure 8). This process could be facilitated by:
- Ensuring that when patients register by phone to schedule an appointment, or if experiencing an emergency, they can indicate language preference and whether an interpreter is needed.
- Creating prompts in scheduling systems for frontline staff to ask about language preference and English proficiency to determine interpreter needs.
- REL data should be documented whenever possible in the electronic medical record to allow ongoing monitoring and easy integration with other reporting systems for quality of care monitoring purposes.
- Patient safety systems should include data fields to track the role of language and culture in the patient safety events reported by staff (go to Figure 9). To support this practice, we recommend that the standard formats for patient safety events be augmented by adding the following fields:
- A field for patient preferred language and English proficiency.
- A field for whether a hospital interpreter was present at the time of the adverse event or was used at any time during the visit.
- A field to document if a hospital interpreter was called and did not show up at the time of the event or during a patient appointment.
- A field to document the use of family or other nonqualified personnel for interpretation during the hospitalization or at the time of the adverse event.
- An open text field that would allow information on the role of cultural values or beliefs to be documented.
|The Health Research and Education Trust's (HRET) Disparities Toolkit (www.hretdisparities.org/index.php ) provides guidelines and resources for systematically collecting REL data from patients. The HRET Disparities Toolkit provides a rationale for the systematic collection of REL data, as well as resources for staff training on how to ask related questions that will assist hospitals in the data collection process.|
We also recommend developing comprehensive data analysis systems and tools to facilitate a better understanding of the root causes of medical errors and adverse events among LEP and culturally diverse patients.
|Only one of the hospitals interviewed as part of our study was systematically documenting language and culture as part of its patient safety reporting system. This hospital utilized a drop-down menu that included the option of "communication" as a factor contributing to the medical errors, and recently expanded the options to include "communication issues with LEP patients," and "interpreter services" (e.g. interpreter did not show up to encounter). This system is just being rolled out and there is no evidence at this time on its effectiveness. It does, however, allow for discussion and feedback from multiple departments, especially if "interpreter services" is documented on the incident report. This allows for a response and negotiation of how to address such situations moving forward.|
Improve Reporting of Medical Errors for LEP Patients
The effectiveness of patient safety reporting systems is predicated on several key conditions. These include user-friendly tools that facilitate reporting, staff who are educated about the issue of safety and the reporting process, and, most important, organizational culture that makes staff members feel comfortable making reports when events arise. Absence of any of these conditions limits an organization's ability to identify and subsequently prevent errors. A fair amount of effort has been spent on developing systems for reporting. The personal component, whether staff feel empowered and have the knowledge and ability to submit a report, has received less attention, particularly as it relates to issues that emerge in LEP patients.
Our research revealed several key areas in need of improvement to ensure that staff are empowered and can identify and report medical errors that occur among LEP and culturally diverse patients:
- Interpreters and frontline staff worry that they will be perceived as spies or snitches if they report errors, making them reluctant to do so.
- Frontline staff and interpreters have limited knowledge about issues related to patient safety. They do not receive training on what constitutes an error or a near miss, or on how to report these when they occur.
- Current safety reporting systems are seen as complicated and burdensome, rather than user friendly.
|The TeamSTEPPS LEP Module provides interprofessional care teams with structured communication tools to help dispel hierarchical challenges and build trust among care team members.|
Develop institutional strategies to empower frontline staff and interpreters to report medical errors, and provide them with the training and systems to do so effectively and efficiently.
- Create a hospitalwide public relations campaign (e.g., National Patient Safety Foundation's National Patient Safety Awareness Week) about the importance of safety reporting, with a particular focus on the issues that frontline staff and interpreters are concerned about (e.g., being viewed as snitches, losing trust of health care providers, being alienated from the care team).
- Develop targeted messages so that frontline staff and interpreters are empowered to report any patient safety events they might encounter.
- Train all staff, particularly frontline staff and interpreters, on the full spectrum of what constitutes a patient safety event (including near misses) and how to report them. Create educational sessions led by the quality and safety team (go to Appendix A for recommendations for training).
- Create or restructure reporting systems based on the "Just Culture" model. This model strikes a balance between blameless reporting and accountable care. It focuses on removing stigma associated with medical errors to allow an open environment of error reporting. Use medical error reporting as a learning tool for greater hospital staff understanding, and expand the array of punitive measures to include lesser penalties for more minor errors.60
- Create or restructure reporting systems that are easy to use and efficient so that even interpreters who are not hospital staff members can complete an incident report quickly.
- Consider developing other methods of identifying errors outside of standard reporting, such as audio-recorded systems, paper, routine focus groups, or conferences with frontline staff and interpreters, especially to capture near misses.
The TeamSTEPPS LEP Module empowers interpreters to be cultural brokers by providing structured communication tools.
The TeamSTEPPS LEP Module trains leaders to hold "Briefs" with interpreters prior to clinical situations.
Routinely Monitor Patient Safety for LEP Patients
To improve quality and safety continually, organizations must routinely generate reports or dashboards that document their performance in achieving quality objectives and reducing medical errors. This process provides opportunities for identifying problem areas and strategies for quality and safety improvement internally while responding to requirements for external reporting. The need for routine, systematic monitoring of quality and safety will only be magnified by the current push for public reporting and new approaches that result from payment reform. As it relates to safety in particular, it is essential that hospitals develop systems to routinely monitor adverse events, and analyze their root causes.
Our research revealed a significant need for improvement in the area of monitoring safety among LEP and culturally diverse patients:
- Hospitals and health systems do not routinely monitor medical errors for LEP patients.
- Hospitals rarely analyze events that occur among culturally diverse and LEP patients.
Develop systems to monitor patient safety among LEP patients routinely, as well as processes to analyze medical errors and near misses that occur among these populations.
- Develop routine (e.g., quarterly, yearly), hospitalwide safety reports or dashboards that focus on patient safety among LEP patients. Link monitoring efforts to a quality committee or patient safety committee to create accountability and assistance with reporting mechanisms. Strategies from the section titled Adapt Current Systems To Better Identify Medical Errors in LEP Patients can provide guidance on how to populate these reports. For example, when one hospital analyzed their patient safety report database by keywords (e.g., language, interpreter, language barrier) and generated a monitoring report, they found the following key issues for LEP patients:
- Care routinely provided without an interpreter.
- Wrong language interpreter being sent.
- Family member or untrained staff person used as interpreter.
- Written translation errors.
- Create routine forums (e.g., M&M-style conferences) to analyze medical errors and near misses among LEP and culturally diverse populations to better understand root causes and high-risk scenarios, and develop strategies for improvement and error prevention.
|The TeamSTEPPS LEP Module provides additional resources on evaluation metrics for monitoring patient safety events, including participant reactions, learning, changes in behavior, and outcomes.|
Address Root Causes To Prevent Medical Errors Among LEP Patients
Medical errors among LEP patients can be prevented by addressing their root causes and by targeted prevention strategies. These strategies might include a focus on particular high-risk scenarios that build on a robust patient safety identification, reporting, and monitoring system.
Our research revealed a need for significant improvement in the capacity of hospitals to prevent medical errors among LEP and culturally diverse patients:
- Dedicated interpreter services—ranging from trained, in-person interpreters to telephonic interpreting, as well as translated materials (e.g., informed consent forms, procedure preparation instructions)—are yet to be commonplace in all hospitals.
- If in-person interpreter services are available at hospitals, they are rarely effectively coordinated to ensure the timely provision of clinical services.
- Staff and clinicians lack awareness about the impact of LEP status on patient safety.
- Interpreters are often not treated as team members or with respect. Several incidents of doctors, nurses, and other staff displaying ignorance, condescension, impatience, and rudeness toward interpreters and LEP patients were reported.
- Limited training is provided to clinicians and staff members on team communication, interpreter use, cultural competence, and patient advocacy.
- A set of policies or protocols does not exist for how to manage high-risk scenarios to prevent medical errors among LEP patients.
Develop strategies and systems to prevent medical errors among LEP patients. These include strengthening interpreter services, improving coordination of clinical services, providing translated materials, and developing training for health care providers and staff on team communication, interpreter use, cultural competency, and advocacy.
- Develop dedicated services for interpretation that include qualified medical interpreters, in person or telephonic (go to Figure 10).
- Provide patients with written materials, such as informed consent forms or procedure instructions, in their preferred written language.
- Identify patients� language needs on boards on the inpatient floors that list current patients and responsibilities.
- Create a mechanism to schedule an interpreter automatically at clinical points of service for LEP patients (go to Figure 11).
- Develop visual cues to remind hospital staff to attend to language and cultural needs (go to Figure 12).
- Train staff on team communication, interpreter use (Appendix A), cultural competency (Appendix A), and advocacy (go to Chapter 3 focusing on TeamSTEPPS).
- Consider other initiatives to improve safety for LEP and culturally diverse patients (go to Figure 13).
At Massachusetts General Hospital, in addition to having in-person trained medical interpreters, each inpatient care unit houses an Interpreter Phone On a Pole, which can be rolled into any patient's room and hooked up to a wall jack to provide telephonic interpretation on demand in any language.
Some hospitals provide patients with an "interpreter requested card" in their language and in English that can be used throughout the care process to notify clinicians and other staff that the patient requires an interpreter. This strategy visually reminds staff of the patient's LEP status and helps encourage patients to participate in their care.
|One hospital described a system that flags previously hospitalized LEP patients at admission and automatically links them to Interpreter Services. The patient is then placed in a queue to be checked on (regardless of whether interpreters conduct rounds to check on LEP patients).|
|Hospitals often devise creative systems to assess and address patients' language needs. One hospital reported using orange bracelets to indicate LEP patients, marking the language on the bracelet so that every care team member would instantly know the patient's language of care. This solution was devised in consultation with the community, and the color orange was chosen because it was not offensive to any of the major language groups represented.|
"When [interpreters are] doing rounds members of the care team sometimes jump onto the bandwagon to communicate essential information about medications. They check in to see if anybody needs them; it's made a big difference in making them available" (Leader, Nursing).
"Some way you build in having physicians, the nurses, the social worker, the case manager, and the interpreter all together in an organized way discussing a patient. I think that would be an improved communication strategy" (Leader, Nursing).
Specific Recommendations for High-Risk Scenarios
Our research suggests that certain high-risk clinical situations need immediate attention to prevent adverse events among LEP patients. Ensuring that resources are available to address these high-risk clinical situations should be a priority. These high-risk scenarios include: medication reconciliation, patient discharge, informed consent, emergency department care, and surgical care.
Below are three key recommendations to address these high-risk scenarios:
- Require presence of qualified interpreters.
- Provide translated materials in preferred language.
- Use "teach-back" to confirm patient understanding.
In brief, requiring the presence of qualified medical interpreters is necessary for all high-risk scenarios. Further, providing translated materials in plain language is critical, especially in the case of discharge instructions, informed consent, and surgical care (e.g., pre- and post-op instructions). Using "teach-back" is an effective strategy to confirm patients' comprehension of care processes, particularly instructions for self-care.