Speaking together: Findings from a hospital disparities collaborative

Organization and Program Description:

Regions Hospital, which is part of the HealthPartners integrated care system, is a 427-bed not-for-profit hospital located in St. Paul, Minnesota.  The Hospital serves a large number of limited English proficient (LEP) patients, with the most common language needs being for Spanish, Hmong, Somali, Vietnamese and ASL interpreters. In 2006, Regions Hospital was one of 10 hospitals nation-wide selected to participate in an 18-month national learning collaborative funded by the Robert Wood Johnson Foundation and housed at The George Washington University School of Public Health and Health Services.  Through hospitals received a $60,000 grant to apply quality improvement techniques to their language services programs to improve the quality and availability of these services for LEP patients. The primary focus of the Regions Hospital team was to improve the percentage of LEP in-patients receiving appropriate language services on three pilot units at two critical points in their hospital stay: nursing admission and discharge.  The core project team consisted of the vice president for patient care, the director of data and measurement, the director of interpreter services, a data analyst and a program intern.

Effective Strategies to Improve Delivery of Language Services:

Regions Hospital saw significant, measured improvement throughout the course of the program in its ability to provide professional interpreters either in person or over the phone to LEP patients admitted to and discharged from its three pilot units. These gains were the direct result of a four-step approach:

1)       Measure true demand for language services and how that demand is being met

• Capture preferred language in the EMR.  This was a HealthPartners-wide initiative driven by senior leadership.  Regular data reviews are conducted to monitor capture rates. Scripting and collection tools have been integrated into employee orientation and posted on an internal website.
  
• Create a documentation tool in the EMR for how language needs are met.  The Regions Speaking Together (ST) team worked with Clinical Informatics to create reportable fields in the EMR to measure encounter-type (admission, teaching, informed consent, discharge, etc.) and how language needs are met for each (in-person interpreter, telephonic interpreter, staff bilingual, family member, etc.)  Drop down menus were embedded into the standard nursing documentation tool.
  
• Measure documentation and focus efforts on increasing compliance.  Regions saw the number of patients with documentation of how language needs were met during their stay increase from 50 to 90 % over the first six months of the program by encouraging consistent and honest documentation.

2)       Leverage hospital and unit leadership and unit champions

• Engage senior leadership to champion project. Both the Regions’ CEO and VP of Patient care participated in unit rounding and program recognition events, spoke about the project at key meetings, regularly reviewed data, and attended national meetings.
  
• Identify key leaders to champion the QI work on a unit level.  The Regions’ ST team worked very closely with nurse managers on each unit and identified one unit champion from the nursing staff on each unit.
  
• Establish regular communication channels to gain timely feedback and relay important messages.   One of the project team did weekly check-ins on the units with nurse managers and champions.  The purpose of these meetings was to 1) ask about successes, barriers and what the team could do to provide additional support and 2) share information such as data reports, educational materials, etc. 
  
• Share data.  The team provided an updated graph of progress each month to the units.  Graphs were posted and shared with unit staff by unit champions.

3)       Conduct “failure analyses”

• Create a tool to record how language needs are met for each LEP admission / discharge.  Regions’ tool included name of admitting or discharging nurse, documentation (yes/no), and how language needs were met.
  
• Share completed tool with nursing leadership on a weekly basis.  Nurse managers were asked to do 1:1 follow-up meetings with nursing staff on each admission / discharge using a prepared script that focused on recognizing success or getting feedback on barriers appropriate service.  Barriers were noted on the tool, which were returned to the Speaking Together team.
  
• Identify trends in failures.  The Regions’ team analyzed the data coming back from the floors to identify trends.

4)       Target improvement and educational efforts to trends and barriers identified through failure analysis

Specific strategies were developed to address each identified barrier and tested using rapid cycle improvement techniques.  Two examples:

Trend:  Significant utilization of family members.

Barrier: Nurses unaware of how to access staff interpreters. Often request them only to have them say they are busy elsewhere.
Change:  Instituted interpreter rounding.  Created daily inpatient lists by language in the EMR and protocol for rounding, which involves having interpreter staff round on units caring for LEP patients to touch base with nursing staff and patients.   Change resulted in greater visibility of on-site language services, better pre-planning to ensure interpreter availability, and opportunities to educate staff on best practice.

Trend: Significant number of failures on admits from ED.

Barrier:  Preferred language not noted on ED RN admit form, so floor staff not aware of a language need until patient arrived on the floor.
Change:  Created a field in ED RN admit form for preferred language so unit staff would know of language need in advance of admission, giving them time to make interpreter arrangements.

The same approach was taken to target educational efforts to identified barriers:

Trend:  Significant utilization of family members.

Barrier: Nurses not sure of how to respectfully communicate with family members regarding the importance of utilizing professional interpreters.
Education: Shared scripting with nurses on how to talk with families about interpreter use as a way to ensure the best possible care.

Barrier: Staff unaware that dual handset phones used to contact telephonic interpreters have speaker function.  In situations where multiple people were present at admission/discharge, nurses felt they could not use this phone and relied instead on family members.
Education: Labeled the speaker function on all dual handset phones and did trainings on how to access telephonic interpreters on all shifts.

Program Results and Key Success Factors

During the course of the Speaking Together collaborative, Regions saw significant gains in the use of professional interpreters for LEP patient admissions and discharges on its three pilot units.  The pilot units were able to move from an average of just under 6% of LEP patients receiving appropriate services at admission and discharge during the first five months of the program to 50% during the final five months, with steady gains in-between.  Key to our success in this work was our focus on:

• Engaging key organizational and unit leaders
• Establishing critical partnership between language services, quality improvement, clinical informatics and nursing unit champions to engage in meaningful QI work
• Treating all unit nurses as “experts” who can provide vital information on barriers
• Implementing interpreter rounding to improve access to interpreters

Also presenting from Regions Hospital during the "Speaking Together: Findings from a hospital disparities collaborative" Peer-to-Peer Practice Advancement Session is Brock Nelson, President and CEO.