Speaking together: Findings from a hospital disparities collaborative

Clinicians and Multidisciplinary Teams are Keys to Providing Effective and Appropriate Language Services: The Case of Hennepin County Medical Center

Hennepin County Medical Center (HCMC) is a comprehensive academic, Level I Trauma, public safety net, teaching hospital servicing Minneapolis and Hennepin County, Minnesota since 1887. The campus includes: 446 inpatient beds, primary care and specialty clinics, the multi-specialty group practice Hennepin Faculty Associates(HFA), the third-largest nonprofit medical research organization in Minnesota – the Minneapolis Medical Research Foundation and four primary care clinics in Minneapolis and suburban Hennepin County. HCMC is based within an urban setting that is its primary patient base. This base includes a broad socio-economic, diverse population with diverse health care needs. These needs range from labor and delivery to primary care, emergency services, psychiatric services and rehabilitation. In addition there is a tertiary referral base of patients that come from the suburbs and rural areas.

The interpreter services department is an integral part of the provision of services to these varied populations at HCMC. HCMC’s interpreter services department was established in 1978 and currently serves an estimated LEP population of between 28 and 40 percent of HCMC’s patients. The history of the development of interpreter services is strongly linked with the immigration of new populations. It started with the need to provide services to Russian, Mung and Spanish speaking populations. Through the years the need for these services grew in numbers and languages. Presently over 68 in-house staff speaking 20 languages delivers language services to this population. The highest demand languages are in order, Spanish and Somali. There are an additional 29 languages that the interpreter’s department coordinates language services for in the support of patient care. In addition they provide sign language services and coordinate hospital efforts in support of CLASS standards. As part of the Speaking Together program, HCMC learned:

• Nurses are critical to ensuring that patients receive timely and efficient language services;
• Effective teams are critical to quality improvement efforts;
• Defining the scope of practice for medical interpreters improves efficiency;
• Organizations must put in place standards for testing bilingual providers to ensure that only qualified language service providers are serving as medical interpreters; and
• Incorporating medical interpreters into medical teams improves patient care as evidenced through increases in depression screening rates.

HCMC will present strategies, tools and techniques that other hospitals and health care organizations can use to improve patient outcomes. To realize these improvements, interpreters must engage hospital administrators, doctors and nurses, and other service providers across departments. Collaboration plays an important role in improving the delivery of language services. At HCMC, the Speaking Together team is leading important discussions with clinicians about how to help physicians, nurses and other frontline staffs determine precisely when a medical interpreter should be requested in order for the patient to get the best possible care. Before engaging in these discussions, the interpreter staff thought it essential to review their professional practice and have a defined practice model. This effort was led by a committee of interpreter staff that did extensive research on community standards, available testing resources and professional standards. This was done through literature review, phone surveys of hospitals and review of professional standards. Their work resulted in the recommendation and adaptation of a practice model for the interpreter’s department consisting of:

• An interpreter’s Scope of Practice
• NCICH Code of Ethics
• NCICH Standards of Practice
• HIPPA Privacy Rule/HCMC Confidentiality Agreement
• Medical Terminology Competency
• Language Testing for defined levels of service.

This practice model was brought forward to the bilingual competency provider committee. Committee members reviewed and supported this model as the framework for establishing quality standards of practice for bilingual providers. The committee membership consists of interpreters, physicians, advance practice nurses, staff nurses, nursing assistants, quality management staff and administration. Quality management and administration were identified as key members to ensure measurement and linkage of quality language services to quality patient care. The committee has engaged in lively discussions focused on complexity of patient service, cultural complexities and level of language skill needed. From these discussions bilingual competency guidelines are emerging. Newly hired bilingual staff is required to meet competency guidelines.

Involving the language services team in discussions about quality improvement is revolutionary because medical interpreters have never before been asked to assess their performance and apply principles of quality improvement to their work. It became clear during the Robert Wood Johnson Grant work that medical interpreters were already identifying concerns about quality of services and possible ways that services could improve. By participating in this initiative, engagement increased among staff. For the first time there was a sustained effort to engage physicians, nurses, other providers and interpreters in discussions around the provision of services to the LEP population. Management learned that despite a large interpreter services department more needed to be done to engage the clinical staff about the importance of language services in providing quality care. It also became clear that the interpreter’s services could be a more integral part of performance management improvement efforts especially in populations with disproportionate health disparities. By engaging the clinical and interpreter staff in joint discussions there was good synergy resulting in beginning solutions to difficult challenges. The key to successfully making progress in these efforts is the engagement of effected staff, clinical leaders, administration and quality management all working towards a common goal of improved patient services and outcomes.

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. Through the Speaking Together program, HCMC focused on improving the quality and availability of language services for patients with LEP. HCMC used grant funds to facilitate their participation in an 18-month learning network to apply quality improvement techniques to their language service programs. HCMC measured performance of its language services programs using quality measures developed by The George Washington University.

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. HCMC assessed the quality of its language services programs and its effectiveness in communicating with patients. The performance measures address multiple dimensions of quality, including safety, effectiveness, patient-centered, timeliness, efficiency, and equity.