Speaking together: Findings from a hospital disparities collaborative

DESCRIPTION

The University of Michigan Health System (UMHS) is nationally known for its quality of care (www.med.umich.edu).  On its Honor Roll of Best Hospitals, US News & World Report ranks Michigan 14th (of 5,462 centers) with Heart as a ranked specialty. The UMHS Cardiovascular Center offers over 25 programs and one is Heart Failure (HF). Per publicly reported HF quality measures (“Core Measures”), UMHS exceeds state and national averages, and is usually in the top 10% of hospitals nationwide (www.hhs.hospitalcompare.gov).  Speaking Together was an opportunity to examine our priorities for HF and cardiovascular (CV) patients who are Limited English Proficient (LEP).  Our aim was to provide HF inpatients with smoking cessation counseling and discharge (DC) instructions in their preferred language.  Two units (inpatient cardiology), the home units for HF patients, were the site of the improvement project.  Inpatient Cardiology includes 10 ICU and 64 telemetry beds, with 202 FTE’s - a staff that includes 146 RNs. Though the LEP population is 3%, cardiac patients are often high acuity and emergent admissions, requiring spontaneous planning for language services.  The units’ existing team of 4 RNs (“GAP Monitors”) did real-time monitoring of HF care, focusing on Core Measures (CM).  The initial plan called for the GAP monitors to identify LEP HF patients and assure that language needs were met -  that smoking cessation counseling and discharge instructions (all 6 dimensions: weight monitoring, medication, activity, diet, worsening symptoms, and follow-up care) were provided in the patient’s preferred language for care.

The evolution of language service departments with qualified medical interpreters has not always kept pace with the education of care providers.  What was perceived as a simple process of translating patient education materials and scheduling interpreters proved to be far more complex.  Barriers to providing quality language services became evident, such as:

• Language screening fields were incomplete or erroneous
• Knowledge of language services varied among clinical providers
• Misinformation and myths about language services led to under use
• Clinical providers lacked “tools”  - the resources needed for LEP patient care

INNOVATION

Project leaders used the “super-user”, an effective model well known to UMHS staff.  Ten RNs self-identified their interest and became ‘unit champions’ - language services super-users. 

Within a period of 6 months, they had:

• Increased their own knowledge of language services by partnering with the Interpreter Services (IS) Department
• Surveyed colleagues to determine baseline knowledge of language services
• Developed a language services power-point program and presented to 65 unit staff
• Re-evaluated staff knowledge of language services
• Consulted on a “Language Services” Resource Binder for unit staff
• Acquired and tested speaker phones to facilitate staff use of phone interpreters
• Created a 4-step process for staff to follow when admitting an LEP patient (referral to IS,  and bedside placement of: ‘I Speak’ sign; speaker phone; a translated word-picture guide)
  

The impact of these changes was evident:

• A composite score was calculated for discharge instructions and smoking cessation counseling. For LEP HF patients, all received instructions in English; 10/13 (77%) were instructed in their preferred language. This was considered an improvement since the issue was not consistently addressed prior to this initiative.
• Over-the-phone-interpreter (OPI) use for cardiac patients spiked soon after staff education, from 150 calls/month in June to more than 300 calls/month in July; this level has continued.  
• Pre- post RN surveys suggest gains: knowledge of OPI increased (34% to 65%). Most RNs (68%) learned about the safety impact of unqualified interpreters from unit in-service [vs. basic nursing program (14.5%)]; 12.9% were still unaware of the issue.
• To meet the need for discharge instructions in writing, multiple HF documents were translated and added to the original online version. By tracking page views, it was evident that all available languages were being viewed. For example, the “Understanding HF” document had ~ 525-850 page views/month and often half were translated versions.
  

These unit-level improvements paralleled organizational improvements in language screening - from 59% to 84% (see also Standiford). As LEP patients on inpatient cardiology attend off-unit appointments in diagnostic and treatment areas, the need to spread these improvements hospital-wide was noted. Using forums such as Nursing Grand Rounds and the annual UMHS Quality Fair, awareness of LEP patients’ needs is growing, and strategies to spread the improvements are underway.

Lessons learned/challenges overcome:

Lessons learned in this initiative were many.Lessons learned in this initiative were many.

• Clinical staff was open and engaged in improving the quality of language services to patients. Unlike other initiatives where resistance can be noted, this was not encountered. The benefit to patient and provider is obvious; with education and resources, staff readily engage.
• Assuring interpreters are used for LEP patient communications was the initial challenge: determining who was LEP, consulting IS, and then documenting use were processes that were not new, but needed enhancement. 
• Educating staff was another challenge. Though an Interpreter Services representative had been a member of the UMHS-wide Nursing Education for several years, there continued to be a knowledge gap. While interpreters may be well-versed on the service they provide, they are not health care providers and may not perceive how and when language issues arise during patient care.  Their perceptions of services such as OPI seemed to be a factor in its underutilization by clinical staff. Once aware of what OPI offered, clinical staff readily accessed the service and saw immediate benefits for problem solving and patient safety.  Unit champions bridged the gap between IS and providers, putting the processes in place that staff thought would work.  
• Since written instructions are required for HF Core Measures, translations were part of the improvement process. With resources available for online translations and variable levels of quality, there is need for a UMHS guideline to address translation practices and formatting. 
• Info Rx, a tool to request patient education materials, includes a field for language. Info Rx facilitated staff access to patient education materials in the patient’s preferred language. Not only has Info Rx made it easy for staff to access resources for LEP patient teaching, it assures the quality of the resources since a consumer health librarian completed the request.

Though challenges exist, clinicians embrace the need to improve the quality of language services, and willingly implement change.