What We Know About Safety and Limited English Proficiency
The Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System states that patients should not be harmed by the care that is intended to help them, and they should remain free from accidental injury.1 The 2001 IOM report Crossing the Quality Chasm defined patient safety as one of the essential components of high-quality health care.2 Patient safety efforts are now a central component of strategies to improve the quality of care for all patients.
The role of language barriers and their impact on adverse events is now receiving greater attention. Recent research suggests that adverse events that affect limited-English-proficient (LEP) patients are more frequently caused by communication problems and more likely to result in serious harm compared to English-speaking patients.3 Further, the Joint Commission has developed a new set of standards on Patient-Centered Communication that emphasize the importance of language, cultural competence, and patient-centered care. Hospitals seeking accreditation will be expected to comply with these recommendations starting in 2012.4
Figure B provides an example of how language barriers can contribute to medical errors.
Why Focus on LEP and Patient Safety?
A Large and Growing Vulnerable Population
Our Nation is becoming increasingly diverse and these issues will be magnified in the future:
- Approximately 57 million people, 20 percent of the U.S. population, speak a language other than English at home.
- Approximately 25 million, 8.6 percent of the U.S. population, are defined as being LEP.5
Thus, at least 8.6 percent of the U.S. population is at risk for adverse events because of barriers associated with their language ability.
Patient Safety, Quality, and Cost Drivers
Quality and cost drivers are emerging in support of work in this area:
- Longer length of hospital stays for LEP patients when professional interpreters were not used at admissions and/or discharge.68
- Greater risk of line infections, surgical infections, falls, and pressure ulcers due to LEP patients' longer hospital stays compared to English-speaking patients with the same clinical condition.6
- Greater risk of surgical delays and readmission due to LEP patients' greater difficulty understanding instructions, including how to prepare for a procedure, manage their condition, and take their medications, as well as which symptoms should prompt a return to care or when to follow up.7,8
- Greater chance of readmissions for certain chronic conditions among racial and ethnic minorities compared to their white counterparts.9, 10 This difference may be caused by limited English proficiency, low literacy, or other communication barriers that make patients more likely to misunderstand discharge and medication instructions.11, 12 With the advent of financial disincentives for excessive readmissions, greater attention should be paid to ensuring effective communication, including appropriate medication reconciliation, at discharge.
Risk management remains a critical concern and is directly linked to patient safety. Multiple liability exposures arise when providing care to LEP populations.13-15 These may include situations related to:
- Patient comprehension of medical condition, treatment plan, discharge instructions, complications, and followup;
- Inaccurate and incomplete medical history;
- Ineffective or improper use of medications or serious medication errors;
- Improper preparation for tests and procedures; and
- Poor or inadequate informed consent.
Accreditation standards mandate advances in the field.
The Joint Commission published Patient-Centered Communication standards in 2011 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook. These standards emphasize the importance of effective communication, cultural competence, and patient-centered care in providing safe care.16
Background: A 65-year-old woman was admitted to a hospital's day surgery unit for release of a trigger finger of the left ring finger. She spoke only Spanish. The day of surgery, no interpreter was available. The doctor, who spoke Spanish, was asked to act as the interpreter during her preoperative preparation. The usual prep procedure was followed with the patient and the correct surgery was confirmed, along with risks and benefits.
Lack of Communication and Teamwork Impede Surgical Procedures:
Resolution: Shortly after, the doctor realized his mistake and followed hospital safety protocols. The correct procedure was performed that day and the patient was discharged. All charges were waived. A legal financial settlement was negotiated shortly after the event. The patient did not return for followup care at the hospital and reported a loss of faith in the doctor.
Ring DC, Herndon JH, Meyer GS. Case 34-2010 — a 65-year-old woman with an incorrect operation on the left hand. N Engl J Med 2010;363:1950-7.
Common Causes of Adverse Events for LEP and Culturally Diverse Patients
Below is a summary of common causes of adverse events for LEP and culturally diverse patients from our research and existing research in the field.
Use of Family Members/Friends or Nonqualified Staff as Interpreters
- Family members and friends typically may not understand the subtle nuances of language and culture that may influence the interaction and may not question the use of medical terminology that they and the patient do not understand. Further, issues of confidentiality may prevent patients from disclosing critical health information.
- Research confirms that untrained hospital staff often serve as interpreters for LEP patients, despite evidence that hospital staff who serve as interpreters on an ad hoc basis are more likely to make clinically significant mistakes than qualified medical interpreters.17, 18
Use of Basic Language Skills To "Get By"
- Clinicians with basic or intermediate foreign language skills often attempt to "make do" or "get by" without the use of a competent interpreter, increasing patient risk.17, 19
Cultural Beliefs and Traditions Affecting Patient Care
- Cultural beliefs and traditions, such as minimizing reports of pain, deferring to authority figures, and following certain gender roles, can influence the medical encounter and compound the risk for LEP patients.
Systems and Strategies To Improve Safety for LEP Patients
Hospitals can engage in a systematic approach to better identify and prevent medical errors and adverse events that commonly occur among LEP patients. Our research has identified five key recommendations to both improve detection of medical errors across diverse populations and prevent high-risk scenarios from becoming safety events. It is important to emphasize that these recommendations represent the ideal system. Hospitals, however, do not need all of these pieces in place to prevent errors for LEP patients.
Some recommendations can be adopted immediately. Other recommendations can be added at a later date, allowing hospitals to work toward preventing errors incrementally. Figure C summarizes key recommendations.
Figure C: Types of Physical Harm Experienced From Adverse Events by English-Speaking and LEP Patients
Foster a Supportive Culture for Safety of Diverse Patient Populations
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 key tools and resources to accomplish this successfully.
- Link the goal of overcoming language and cultural barriers into the overall message and mission of the culture of quality and safety, and frame this within existing operational policies 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 continuous learning and training in this area.
- Involve patients in family advisory councils or cultural advisory groups to incorporate patient perspectives.
Adapt Current Systems To Better Identify Medical Errors Among LEP Patients
- Adapt current systems to better identify medical errors in LEP patients, improve the capacity of patient safety systems to capture key root causes and risk factors, and link databases so that information is readily accessible.
- Document data in the electronic medical record on race, ethnicity, and patient language and interpreter service needs to allow ongoing monitoring and easy integration with other reporting systems for quality of care monitoring purposes.
- Include these data fields in patient safety systems to track the role of language and culture in the patient safety events reported by staff.
Improve Reporting of Medical Errors for LEP Patients
- Develop institutional strategies to empower frontline staff and interpreters to report medical errors, and provide them with training and systems to do so effectively and efficiently.ii
- 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.
- Consider other methods of identifying errors outside of standard reporting.
Routinely Monitor Patient Safety for LEP Patients
- Develop systems to routinely monitor patient safety among LEP patients, as well as processes to analyze medical errors and near misses that occur among these populations.
- Develop routine (quarterly, yearly) hospitalwide safety reports or dashboards that focus on patient safety among LEP patients.
- Create routine forums for analyzing cases of medical errors and near misses that occur among LEP and culturally diverse populations to better understand root causes and high-risk scenarios, and develop strategies for improvement and error prevention.
Address Root Causes To Prevent Medical Errors Among LEP Patients
- Develop strategies and systems to prevent medical errors among LEP patients by strengthening interpreter services. Improve coordination with the provision of clinical services, provide translated materials, and develop training for health care providers and staff on interpreter use, cultural competency, and advocacy. Immediate strategies that can be implemented are improving access to interpreters (Figure D presents an overview of benefits and challenges of interpreters providing cultural brokerage) and offering TeamSTEPPS® training (Figure E).
- Develop dedicated services for medical interpretation that include either in-person or telephonic qualified medical interpreters, or both.iii
- Provide patients with written materials – such as for informed consent or procedure preparation – in their preferred written language.
- Create a mechanism to schedule an interpreter automatically at clinical points of service for patients who are identified as having LEP.
- Train staff on team communication, use of interpreter services, cultural competency, and advocacy by using the new TeamSTEPPS LEP Module.
Interpreters who serve as cultural brokers in addition to interpreting:
While these benefits may reduce medical errors, challenges to interpreters serving as cultural brokers include:
Participants in the TeamSTEPPS LEP Module will be able to:
iiThe term "frontline staff" includes all patient-facing staff such as registrars, medical technicians, medical assistants, interpreters, and nurses.
iiiFluent bilingual staff are also a form of language assistance and medical interpretation proficiency should be verified.
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. These high-risk scenarios include: medication reconciliation, patient discharge, informed consent, emergency department care, and surgical care. Ensuring that resources are available to address these high-risk clinical situations should be a priority.
Three key recommendations to address these high-risk scenarios are:
- Require presence of qualified interpreters.
- Provide translated materials in preferred language.
- Use "teach-back" to confirm patient understanding.
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, specifically instructions for self-care.
Improving Team Communication To Foster Safety for LEP Patients: TeamSTEPPS® LEP Module
It may take some time to create a system to monitor and prevent errors for LEP patients. Fortunately, several activities can be implemented to prevent errors in the short term. Primary among these is use of the TeamSTEPPS LEP Module.
In November 2006, the Agency for Healthcare Research and Quality, in collaboration with the Department of Defense, released Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) as the national standard for team training in health care.20 TeamSTEPPS is an evidence-based teamwork system designed to optimize patient outcomes by improving communication and other teamwork skills among health care professionals. The approach is scientifically rooted in more than 20 years of research and lessons from the application of teamwork principles.
TeamSTEPPS was originally successfully implemented through military health care and has recently been expanded nationally and implemented at hospitals across the country. Recent research has shown that TeamSTEPPS is effective in multiple settings at improving care outcomes, team communication, and team attitudes.21-24 Unlike other team-based trainings, TeamSTEPPS is evidence based, field tested, comprehensive, and customizable. It provides easy-to-use teamwork tools and strategies and is publicly available at no cost.
AHRQ has created the TeamSTEPPS LEP Module to help hospitals improve patient safety for LEP patients. The purpose of the TeamSTEPPS LEP Module is to train interprofessional care teams working together in hospital units (such as OB-GYN, emergency departments, and surgery) on the knowledge, attitudes, and team behaviors needed to reduce the number and severity of patient safety events affecting LEP and culturally diverse patients in their unit (Figure E).
The TeamSTEPPS LEP Module trains doctors, nurses, technicians, front desk staff, and interpreters together to improve team dynamics and prevent miscommunications when working with LEP patients. TeamSTEPPS creates a psychologically safe environment for others to clarify misunderstandings through the use of tools such as briefs, check-backs, and teach-backs. The TeamSTEPPS LEP Module can be used in hospitals that have not implemented any other TeamSTEPPS training.
Frequently Asked Questions
With everything else that hospitals are dealing with, why focus on the safety of LEP patients?
Currently, approximately 57 million people, or 20 percent of the U.S. population, speak a language other than English at home. Approximately 25 million, or 8.6 percent of the U.S. population, are defined as limited English proficient (LEP), meaning that they speak English less than "very well."5 This number is expected to grow, as projections indicate the United States will continue to become more diverse. This growing segment of the U.S. population is at risk for adverse events because of barriers associated with limited English proficiency. Furthermore, failing to address language barriers can lead to significant financial risk, as well as human cost.
From the standpoint of quality, poor communication that leads to ineffective medication reconciliation at discharge may lead to avoidable rehospitalizations that will not be reimbursed. Poor communication may also lead to delays in informed consent or postponing procedures due to inappropriate preparation. The cost of delayed surgical procedures was estimated in 2004 as $70 per minute.25
Improving safety for LEP patients may also reduce malpractice liability. A recent study examined medical malpractice claims of a malpractice carrier that insures in four States. Researchers found that 35 claims (2.5 percent of the carrier's total claims reviewed) were related to language barriers.14 The carrier paid $2,289,000 in damages or settlements and $2,793,800 in legal fees from January 2005 to May 2009. Many of the cases reviewed resulted in patients suffering death or irreparable harm. Most were due to failure to use an appropriate interpreter.
As we look toward the future, this issue will take on greater importance and hospitals must be prepared to provide safe, high-quality care to patients from diverse social, cultural, and linguistic backgrounds. Finally, Joint Commission standards require hospitals to document all relevant data to help staff coordinate communication assistance (e.g., language, cultural or religious accommodations), create processes to identify patients with unique needs, and provide the necessary equipment throughout the care continuum.
We know that LEP patients may have trouble communicating with the health care team, but how does that relate to patient safety?
Evidence shows that unaddressed language barriers put patients at high risk for adverse events. For example, LEP patients are more likely to experience medical errors due to communication problems than English-speaking patients and are more likely to experience physical harm when errors occur.3 Further, pediatric patients with LEP families who speak Spanish have a much greater risk for serious medical events during hospitalizations than patients whose families are English proficient.26 Given the communication challenges LEP patients face, it is critical that hospitals make special efforts to address the role of language and cultural factors so that LEP patients receive safe and effective care.
Only a few patients at our hospital don't speak English well enough to at least get by, so why should we spend time and resources on professional interpreter services?
This is a very reasonable question. Your hospital may have more patients with language barriers than you think since many LEP patients appear to communicate reasonably well in English. However, many LEP patients may not understand critical information and may not be able to express important concerns or ask relevant questions. Numerous studies on language barriers in health care confirm this situation.
Poor communication can lead to medical errors, patient safety events, and overall lower quality of care. Patients may not feel comfortable revealing that they have trouble communicating in English. Thus, it is important to offer professional interpretation services, even when patients seem to speak enough English to "get by." In addition, the Department of Justice and the Department of Health and Human Services have stated that failure to provide appropriate interpreter services can be considered discrimination based on national origin. Such discrimination is prohibited by Title VI of the Civil Rights Act of 1964 for any entity receiving Federal funding such as Medicare or Medicaid payments.
It is the responsibility of immigrants to this country to learn English, so why do we need to focus so much attention on providing care in their own language?
While it is certainly helpful when patients learn English, this is not a requirement for receiving medical care or for living in the United States. Regardless of your perspective on this issue, learning a new language takes time and can be particularly difficult, especially as we advance in age. Helping patients gain access to English as a second language (ESL) courses is one step.27 However, LEP patients, including those who speak English but are not comfortable discussing important medical issues in English, still deserve to receive effective health care that they can understand.
Medical information is difficult to understand even if English is your native language; it is even more difficult for LEP patients who may struggle with both linguistic and other cultural barriers. Further, the law requires that LEP patients seeking health care be afforded the same opportunity to communicate with the care team as English-speaking patients. Generally, this means effective interpreter services. Interpreter services benefit not only the patient, but also staff members who otherwise struggle to ensure the provision of high-quality care.
Many LEP patients come with family members or friends who can interpret for them. Isn't this enough to communicate with them in the clinical setting?
Health care staff should understand the risks of using nonqualified interpreters, including family members, friends, or untrained staff. These "ad hoc" interpreters are not trained or skilled in the interpretation process, such as the need to interpret everything the clinician and patient say, to interpret manageable chunks of information, and to avoid paraphrasing long explanations.
Family members are not neutral parties to the medical encounter; they may withhold information from the clinical care team or from the patient, or may add their own perspectives. They may also be distressed, interfering with their ability to interpret. Research has shown that all of these problems can lead to miscommunication and patient safety issues, as ad-hoc interpreters have been shown to commit more communication errors of clinical significance than trained interpreters. Family members may also suffer psychological harm if they make an error in interpretation that results in harm to the patient. Staff should inform patients that they have a legal right to an interpreter at no cost, and that family members are welcome to be involved in the conversation if the patient wants but should not bear the burden of serving as interpreters.
Our hospital has in-person interpreters for many languages and phone interpretation for the rest. Isn't that enough to make sure we're providing safe and effective care for LEP patients?
Although it is critical to ensure that you have qualified in-person medical interpreters (or access to telephone or video) for the languages reflecting the patient populations you serve, this is not enough to ensure safe and effective care for LEP patients. For example, staff may not call interpreters when needed, service may be delayed, and interpreters may not be empowered to speak up when they recognize miscommunication or a potential adverse event.
Having interpreter services available is not helpful if they are not used effectively. All staff should have training on how to use interpreter services and should understand the interpreter's role in the patient encounter. This includes fostering a culture of safety for LEP patients where the entire care team, including the interpreter, is prepared to identify and address potential safety issues. Interpreters should receive standardized training in how to interpret effectively and in relevant aspects of clinical care. The National Council on Interpreting in Health Care and the International Medical Interpreters Association have developed national certification standards to guide the design of services, processes, and programs to ensure quality control and accountability.
Aren't interpreters supposed to simply translate what is said word for word rather than getting involved in any other aspect of patient care?
The role of an interpreter has traditionally been limited to strictly interpreting word for word the conversation between patients and clinicians (or other health care staff). However, research3,26,28 has shown that interpreters can play a critical role in helping to reduce medical errors given their unique position in the medical encounter. Therefore, they should be empowered to more fully participate in the interaction to ensure patient safety.
Interpreters should be welcomed and treated as core members of the care team for LEP patients. They should be empowered to speak up if they recognize that a patient's safety is at risk, particularly due to miscommunication or cultural misunderstandings. They can act as cultural brokers to improve the interaction between clinicians and patients. Further, interpreters can be integrated into team meetings, especially for complicated LEP patients, and can participate in huddles, briefings, debriefings, handoffs, and discharges as described in this guide.
Our organization has not focused much attention on this area before, so where do we start?
An important first step is to assess whether current language assistance meets the needs of patients speaking common languages other than English in your hospital. If it does not, work on hiring bilingual staff and building up interpreter services. Once your language assistance is well matched to patients' needs, you can launch other initiatives. These include clarifying hospital policies about how patient language needs are assessed, when interpreters should be called, and how proficiency of bilingual staff is established.
Even if your hospital collects language and interpreter needs data, it is important to make sure that the questions are asked effectively and the data fields are appropriate. You may need to modify tracking and reporting systems by creating fields to capture language preference and interpreter use. This process can help you more accurately track how patients' language affects patient safety.
Finally, you can use the new TeamSTEPPS LEP Module, which is designed to engage staff in improving patient safety for LEP patients. This guide will present more information on how to start building a safe and effective care environment for LEP patients.
What are the key barriers to implementing initiatives to address LEP patient safety and how might these be overcome?
First, awareness about safety risks for LEP patients may be low. Educating hospital staff at all levels about the need to create a culture of safety, particularly for LEP patients, will be key in getting staff buy-in. Second, many hospitals do not have the information technology in place to capture data to ensure timely language assistance. Adding the necessary fields and functionality, however, is always possible if leadership makes it a priority.
Third, even if the technology is in place, the data need to be collected properly. The good news is many successful models can help you achieve this goal. Evidence demonstrates that the registration process should include standardized mechanisms to collect and verify language needs, such as specific templates for data collection. It is also important to train registrars. Fourth, the data frequently are not used to access language assistance. Hospitals need to have interpreter services available (in person and by phone or video) and train staff to call for interpreters and to interact with them effectively.
This brings us to the fifth barrier, the hierarchical structures in hospital that frequently prevent subordinate staff from speaking up when they see a patient safety threat. This is particularly a problem with interpreters who are often not integrated into the care team. Training, such as the TeamSTEPPS LEP Module, can empower staff and provide them with communication tools to prevent, identify, and report medical errors among LEP patients.