Speaking together: Findings from a hospital disparities collaborative

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.  From 2006-2008, Speaking Together focused on improving the quality and availability of language services for patients with limited English proficiency (LEP) in hospital settings. The program awarded a grant to Cambridge Health Alliance (CHA) to facilitate their participation in eighteen-month learning collaborative to apply quality improvement techniques to their language service programs using a standard set of quality measures. CHA is an academic public health care system which includes three acute care hospitals, more than 20 primary care sites, and the public health department for Cambridge, MA. CHA's interpreter services has over 44 full time and 100 per diem interpreters, and contracts with freelance interpreters, agencies, and telephonic interpreting vendors. The Multilingual Interpreting Department provides around-the-clock coverage for more than 60 languages, with most interpreting provided face-to-face.  Utilization of telephonic interpreting is quickly increasing through a readily-available internal phone interpreting system, with calls automatically rolling over to an outside phone interpreting vendor when CHA interpreters are unavailable.  One of the clinical focus areas for the Speaking Together project at CHA was the East Cambridge Health Center (ECHC). ECHC is one of CHA’s 20 multidisciplinary health centers offering primary care, OB/GYN, and mental health services.  Each of CHA's health centers and patient populations have a distinctive linguistic profile.  At ECHC, 74% of the patients speak Portuguese as their primary language. This includes a population of immigrants from Portugal and the Azores who have been living in the area for many years and a population of more recent immigrants from Brazil. Language services at ECHC are provided via two full-time Portuguese interpreters on site, additional per diem interpreters, and telephonic interpreting, as well as bilingual staff and providers.

One of the quality measures for the Speaking Together collaborative was the percentage of LEP patient visits with initial assessment and discharge instructions from assessed and trained interpreters or bilingual providers assessed for language proficiency. All patients at CHA are asked their primary language spoken in the home, their care language preferred for clinical visits, and their written language preferred for health-related materials. A patient is identified as LEP within the system if s/he responds to any of three language questions with a language other than English. Several enhancements for serving LEP patients were developed through a multidisciplinary collaboration that included interpreter services, providers at ECHC, Information Technology, and Quality Management. Innovations include: 1) documentation of how patient language needs are met in the EPIC electronic medical record in a way that facilitated reporting, and 2) progress toward developing a system for provider fluency testing. Each patient record in EPIC has a header with key information visible to the provider. One change stimulated by Speaking Together was updating the EPIC banner, which was changed to display the patients' care language preference to increase providers' awareness of the patients' needs for language assistance.  A system for documentation of how patients’ language needs are met was also programmed into EPIC. For those patients with LEP, providers then select from a limited number of options as to how language needs were met: Interpreter (face to face, phone or video), Provider fluent in patient's language, Family or friend preferred, English preferred by patient today, or Bilingual employee. Means of meeting patients’ language needs that were optimal (assessed and trained interpreters or bilingual providers) as well as other options were included in the response options in order to facilitate accurate reporting with a comprehensive list to give a true assessment of how well language needs were being met at ECHC. Provider feedback was incorporated into the development of the documentation process as a means to ensure that the process was quick, user-friendly and would lead to accurate documentation of how language needs were met for every assessment and discharge.

Over the course of Speaking Together, 39 to 43% of LEP patient visits had an interpreter or a fluency tested bilingual provider for assessment and discharge. Reports for ECHC showed that more LEP patients had their language needs met with bilingual providers than with interpreters. At the beginning of Speaking Together, none of the bilingual providers had fluency testing. Over the course of the project, staff discussion identified key issues related to using one's own linguistic skills versus working with an interpreter. These included: timeliness in interpreter access, increased appointment time required for visits with interpretation, impact of delay on clinic flow and compensation, access to fluency tests measuring the language skills of bilingual providers in a primary care setting, how to support language competency development, fluency standards, and compensation for bilingual skills. CHA/ECHC leadership was engaged to raise awareness about risks associated with miscommunication and took steps to find tests that measured linguistic skills of bilingual providers (different from interpreter skills), identified an outside vendor to perform voluntary testing of providers, identified resources standards for a range of linguistic challenges, and agreed to focus efforts on improving interpreter access, both face to face and telephonic.  By the end of the project, two providers, including the medical director, had piloted various fluency tests, demonstrating that voluntary bilingual provider fluency testing is possible with sensitive and responsive leadership.

Speaking Together is the first initiative to bring together hospitals to apply quality improvement techniques to language services. CHA/ECHC used the measures to assess the quality of their language services programs and their effectiveness in communicating with patients. The performance measures used by CHA/ECHC addressed multiple dimensions of quality, including safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The primary lesson learned through Speaking Together at CHA/ECHC was that monitoring and improving language access requires collaboration across disciplines, engaging leadership and staff of the clinical area served, interpreter services, quality, and IT. Harnessing the power of the EMR to monitor how and how well language needs are met is very promising and will allow for the development of performance benchmarks and quality monitoring within language services for the myriad of ways in which patient language needs are met.