Speaking together: Findings from a hospital disparities collaborative

About the Program

Limited-English speaking populations continue to grow in communities across the United States and hospitals and health care providers need tools and methods to communicate better with these patients. Persons with limited English proficiency (LEP) are not only less likely to receive primary care and preventive services, but are also less likely to receive the same quality of care as English proficient patients.

With organizations required to address language barriers as part of health care delivery, hospitals can benefit from the learning and strategies that have been demonstrated to improve access to effective language services.  Because few hospitals have applied quality improvement techniques and standardized performance measures and data to guide delivery and operations of language services, the experience of the hospitals in Speaking Together is a critical step towards eliminating language barriers in health care. 

Speaking Together is a national program funded by the Robert Wood Johnson Foundation and housed at The George Washington University School of Public Health and Health Services.  Speaking Together focused on improving the quality and availability of language services of patients with LEP in hospital settings.  The program awarded grants to hospitals to facilitate their participation in an 18-month learning network to apply quality improvement techniques to their language service programs.

Speaking Together was launched in November 2006, following a competitive grant application process that resulted in the selection of 10 participating hospitals. To be eligible, hospitals had to have a substantial number of LEP patients (in inpatient and outpatient settings) to make quality improvement efforts meaningful, an established language services department, and at least some on-site interpreters who were employees of the hospital. The hospitals selected to participate in Speaking Together each received a $60,000 grant plus intensive technical assistance throughout an 18-month learning network.

Innovations and Successes

Speaking Together is the first initiative to bring together hospitals with high volumes of patients with LEP to apply quality improvement techniques to language services.  Speaking Together developed a multi-staged process to identify a core set of measures that could ultimately be used by hospitals interested in doing quality improvement in this area.  What emerged from this process were five measures that have been used throughout the Speaking Together Learning Network to gauge progress in the 10 participating hospitals. The Speaking Together measures focus on evaluating screening for preferred language, receipt of language services from qualified providers, patient wait time for an interpreter, time interpreters spend in medical interpretation, and Interpreter wait time.

The measures provide uniform tools for hospitals to assess the quality of their language services programs and their effectiveness in communicating with patients.  The performance measures address multiple dimensions of quality, including safety, effectiveness, patient-centered, timeliness, efficiency, and equity. As part of a national learning collaborative, ten institutions (including Cambridge Health Alliance, Hennepin County Medical Center, and Regions Hospital) worked for 18-months to measure and improve language service operations.  Participants were trained in Rapid Cycle Change (RCC) strategies–a quality improvement technique that uses a “plan-do-study-act” model. RCC allows organizations to test and measure changes on a small scale before spreading to the rest of the organization. In addition to training in RCC and standard performance measures for language services, ST hospitals also received data collection and improvement tools to measure performance and document strategies. Performance data was also collected monthly in one or more of the following areas: cardiovascular disease, depression, and diabetes mellitus.

The experience of hospitals participating in this learning collaborative shows that hospitals can use traditional quality improvement techniques and performance measures to improve the quality and efficiency of language services.  All hospitals were able to use data from performance measurement to implement successful interventions to improve efficiency and effectiveness of operations.  Specifically, hospitals have used performance measures and quality improvement techniques to: better understand and meet demand for language services; ensure that language services are in place at critical times; involve providers in ensuring access to appropriate language services; and provide timely services.

Small, targeted changes can produce substantial improvements in language services delivery.  With language services representing an unreimbursed service in most states, hospitals can use data about language services to identify opportunities to realize operational improvements.  As a result, health care professionals can use this information to implement tools and strategies to improve the quality and availability of effective language services.

Lessons Learned

Language services are absolutely critical for health care organizations with diverse patient populations and a desire to deliver safe, quality care. The work of Speaking Together has shown that hospitals can achieve high-quality by embedding language services into the fabric of clinical care. Among the many lessons learned:

• Language services deserves a voice in every discussion about improving quality:  Communication is essential to quality. Language services need to be included in improvement efforts in the organization.
• Meaningful improvement is possible:  The Speaking Together hospitals demonstrated that quality improvement techniques can be applied to language services for the purposes of measuring and improving performance.
• The power is in the data:  Hospitals can report data on language services performance and use this data to engage clinicians and leadership in making change in the organization.
• Clinician involvement is key:  Clinicians are ultimately responsible for making sure that the language needs of their patients are met. Without clinician involvement, an organization cannot ensure that all patients are receiving quality care.
• Language services cannot “go it alone”:  The language services department can work to improve the quality and accessibility of services, but it takes a multidisciplinary team to measure and improve the quality of language services delivery—including, but not limited to clinicians, frontline staff, registration and scheduling staff, quality improvement departments and senior leadership.
• Investment is necessary to achieve quality:  Like many services in health care, some investment of time and financial resources is necessary to improve the quality of language services. Individuals responsible for allocating resources in an organization need to make a commitment to language services in order to improve overall quality of care.

Advances in quality improvement do not come easily. The accomplishments of the Speaking Together hospitals show that with commitment, tried and true strategies, and the right foundation for success, organizations can support high-quality language services delivery.

Learning Objectives:

• Benefit from the learning and strategies that have been demonstrated to improve access to effective language services. Because few hospitals have applied quality improvement techniques and standardized performance measures and data to guide delivery and operations of language services, the experience of the hospitals in Speaking Together is a critical step towards eliminating language barriers in health care.
• Learn from the experience of a collaborative learning network that used performance measures and clinical measures to improve services and patient outcomes.
• Identify successful policies and strategies for impacting quality of care in language services programs.