SummaryUMass Memorial Medical Center's Language Services Department uses a comprehensive process to ensure that patients with limited English proficiency and those who are deaf or hard of hearing have timely access to interpreter services. The department also uses data collection and analysis, monitoring systems, and interpreter educational requirements to ensure the quality of such services. The program has reduced patient waiting time for an interpreter, increased the number of languages in which interpretation services are available and the number of interpretations provided, and reduced length of stay for patients requiring interpreter services.
See the Description section for information on how technology has centralized and streamlined many aspects of this program; see the Results section for new data on how this program has affected length-of-stay and readmission rates; see the Adoption Considerations section for updated advice on using quality-improvement methodologies and electronic systems (updated April 2013).Moderate: The evidence consists of pre- and post-implementation comparisons of key measures related to interpreter services, including patient waiting times, available languages, and number of interpretations provided. The evidence also includes a retrospective analysis comparing average length of stay for patients with limited English proficiency who receive interpreter services with a similar group not receiving such services.
Developing OrganizationsUMass Memorial Medical Center
Date First Implemented2006
Vulnerable Populations > Non-english speaking/limited english proficiency
Problem AddressedMore than 55 million people speak a language other than English in their homes,1 and many of these individuals experience communication barriers when they seek inpatient and outpatient care that negatively affects access to and quality of care in these settings. Although trained medical interpreters can help to reduce these barriers, a number of patients lack ready access to high-quality interpreter services.
- A common problem that affects access to care: Individuals with limited English proficiency are less likely than those whose first language is English to have a regular source of primary care2 and to receive preventive services.3 A national survey of insured, nonelderly adults found that Spanish-speaking Hispanic patients were less likely to visit physicians and mental health professionals and to receive influenza vaccinations and mammograms than non-Hispanic white patients.4
- Negative implications for quality: Communication barriers impede understanding of—and hence adherence to—treatment plans and therapies in patients with limited English proficiency.5 Patients who need but do not have access to an interpreter are less likely to understand instructions for taking medications, receive information on medication side effects, and be satisfied with their care.6,7 The failure to provide interpreters leads to poorer patient comprehension of diagnosis and treatment, higher hospital admission rates, increased testing, improper treatment, and misdiagnosis.8,9,10
- Growing demand for high-quality interpreter services: High-quality interpreter services can help to reduce communication barriers and therefore improve access to and quality of care. Yet, many patients lack ready access to such services. Title IV of the Civil Rights Act of 1964 requires that entities receiving Federal funds provide language services when needed; however, the law has not always been enforced in health care settings.11 As the demand for interpreter services in health settings grows, so does the need to develop policies and procedures to maximize access to interpreters and ensure the provision of high-quality interpretation services. Such was the case for UMass Memorial Medical Center, which offered interpreter services in more than 50 languages and served a patient population speaking approximately 85 languages at home.12
Description of the Innovative ActivityUMass Memorial Medical Center's Language Services Department uses a comprehensive process to ensure that patients with limited English proficiency and those who are deaf or hard of hearing have timely access to interpreter services in more than 136 languages. The department also uses data collection and analysis, monitoring systems, and interpreter educational requirements to ensure the quality of such services. Key program elements include the following:
- Comprehensive process to enhance access to interpreter services: The Language Services Department uses a comprehensive process designed to ensure that those who need an interpreter are identified early and gain quick access to needed services. The process works as follows:
- Identification of need at point of registration: Patients are asked their preferred language to receive health information during their initial point of contact with the medical center, at the same time that basic demographic and insurance information is collected. (Although most patients can answer this question verbally or have a bilingual family member or friend who can do so, patients registering in person can also point to a language list if necessary.) The registration staff contacts a telephone-based interpretation service (operated by a vendor under contract with the hospital) to help gather the needed information for those who do not speak English; three-way calling is available to facilitate communication among the patient, interpreter, and staff member. Forcing functions in the hospital's registration system make identification of a preferred language a "required field." These required fields have drop-down lists to remind staff to verify language information, including primary language, preferred language to receive health care (with 136 languages listed), and whether an interpreter is needed. A free-text field allows staff to enter languages not included in the drop-down list. In addition, Language Services staff have the ability to correct these fields at any point during or after their interactions with the patients.
- Use of a centralized, online system to handle pending call requests: Information provided in April 2013 indicates that when patients with limited English proficiency call the hospital (or are referred from an individual clinic), they are prompted to select their preferred “language line” to leave messages requesting callbacks. Interpreters retrieve these messages and upload all pending requests in a centralized SharePoint database, allowing all Language Services staff to see the full list of pending requests. Automated alerts also notify interpreters as to which calls are pending and for how long. Using this electronic system to handle patient calls (as opposed to the previous paper-based system) allows staff to respond to requests in a more timely fashion.
- Information about accessing interpreters for inpatients: When unit nurses reference an inpatient's medical record and see that linguistic services are needed, they must tape a poster to the door of the patient's room indicating the patient's language preference and listing instructions for providers on how to access an interpreter, either through the Language Services Department or the telephone-based service. (Hospital policy requires that posters be displayed on the doors of all patients with limited English proficiency or who are deaf or hard of hearing.) The poster encourages providers to preschedule interpreter services whenever possible. Language Services staff perform daily rounds to verify the appropriate placement of posters; noncompliance is reported to the unit manager. Information provided in April 2013 indicates that the medical center prints out a “daily census” of language services needed by inpatients (by floor), which helps providers and other staff review this pertinent information before beginning their shifts. This information can also be sent to staff via automatic e-mail notifications.
- Processing requests: The medical center uses the following process to assist Language Services dispatchers with prioritizing and filling requests in a timely and accurate manner:
- Electronic calendar reflecting interpreter availability: Interpreters (both day and night shifts) post their weekly availability on an electronic calendar; outpatient schedulers and Language Services dispatchers refer to the electronic calendar when scheduling interpreters.
- Scheduling of interpreters for outpatients: Language information collected during registration automatically transfers to the scheduling system. When outpatient schedulers access the system, they receive alerts about the need for an interpreter and can request one at the same time they book the medical appointment.
- Prescheduled requests: Schedulers receive interpreter requests and arrange for telephonic, onsite, or contracted interpreters. Information provided in April 2013 indicates that the medical center has shifted from a paper-based system to a centralized electronic database. Once language services have been requested, the schedule can be downloaded and manipulated electronically. This allows schedulers to more easily verify availability of interpreters and align the scheduled interpretation services with the provider appointment times. It also allows the medical center schedulers to print and e-mail personalized schedules and reports for each interpreter and provider, as needed. The Language Services Department sends an automated e-mail 48 hours in advance of appointments to inform providers when the interpretation will be provided and whether the format will be in person or by telephone.
- Same day (unplanned) requests: For same-day requests on inpatient units, medical center staff can now place an electronic order to request an interpreter, similar to ordering other medical services such as blood work or computed tomography (CT) scans (updated April 2013). The order includes all pertinent information for the request, including the department making the request, provider’s name, patient’s name, medical record number, the language requested and the time the request is needed. The electronic order is uploaded into the centralized database where dispatchers can access pending requests and then dispatch an interpreter accordingly. The status of the request is marked as pending, in process, or completed. Outpatient clinics call in their requests and dispatchers log the request/order into the centralized computer system. If the expected wait time for an inperson interpreter is unacceptable to the requester, the dispatcher can immediately connect the requester to a telephone-based interpreter or page an inperson interpreter to arrange for reassignment.
- Expanded interpreter capacity: The hospital expanded interpreter capacity by adding onsite staff interpreters to the night shift and by contracting with a telephone-based vendor for interpreter services in uncommon languages. (The hospital maintains high-quality portable speaker phones on inpatient units to facilitate telephonic interpretation.) The hospital also works with the clinics to set criteria for interpreter needs, as it is impractical to have inperson interpreters in every situation. Whether a patient receives inperson or telephonic interpretation depends on several factors:
- Availability of interpreter/language: Telephone interpretation is nearly always used for less common languages. It is also used for common languages when an inperson interpreter is not available. Clinics have direct access to an over-the-phone interpreter, as opposed to going through a third party or scheduling service. The ability to access this service quickly and efficiently has increased interpreter capacity significantly (updated April 2013). The medical center actively monitors this service to ensure the timeliness and overall quality of this form of language interpretation (see below for more on vendor evaluation).
- Medical considerations: Providers may specifically request an inperson interpreter based on the patient's medical circumstances or procedure complexity. Schedulers also know that certain procedures require an inperson interpreter; for example, schedulers automatically book an inperson interpreter (either someone on staff or a contractor) for those receiving a CT scan with contrast.
- Complexity of situation: Providers treating a complicated patient may request an inperson interpreter. However, in other situations (e.g., registration), telephone-based interpretation is generally sufficient to ensure thorough communication.
- Use of glossaries: Interpreters use internally developed glossaries of medical terms in the most common primary languages (Spanish, Portuguese, Vietnamese, and Albanian) requested by patients.
- Communication, data collection, and monitoring systems to ensure quality: The Language Services Department uses communication, data collection, and monitoring systems to ensure the quality of interpreter services; a selection of systems is described below:
- Electronic transfer-of-shift log: A transfer-of-shift log allows interpreters and dispatchers to convey relevant information about current patients and pending requests to staff working the next shift. This previous paper-based log is now maintained in a shared electronic file.
- Systematic data collection and analysis: Interpreters complete an encounter form for every patient assignment (even "no shows"), which lists the patient's name, location/department of the interpretation, and time of the request. The interpreter completes information about arrival time and interpretation start and end times. Encounter forms are submitted at the end of the week for data processing and analysis, including calculation of patient wait times, interpreter wait times, number of patients receiving interpretations, the percentage of requests that are prescheduled, and the percentage of no shows. These data help to stimulate quality improvement.
- Ongoing evaluation and support: The quality of services provided by staff and contract interpreters is evaluated and supported on an ongoing basis, as outlined below:
- Evaluation, education, and mentoring: All employed interpreters are evaluated before being hired, after 3 months on the job, and on an annual basis thereafter. The evaluation covers oral fluency and interpreting skills, including completion of a department-developed evaluation of competency and terminology. The hospital has also mandated that all interpreters complete a minimum of five continuing education training sessions annually. To assist in fulfilling this requirement, the department hosts monthly training sessions. Last, an assigned mentor supports all interpreters, with mentor selection based on their experience and job performance.
- Vendor evaluation: Language Services staff perform real-time evaluations of vendor-provided interpreter services two or three times a week in ambulatory care clinics. A staff member alerts the provider and patient in advance that an evaluation will be performed and then joins the appointment by telephone. The staff member evaluates the interpreter on patient and provider interaction, language skills, and terminology. After each call, the evaluator completes a report and provides feedback to the vendor.
- Data centralized in a single repository: Information provided in April 2013 indicates that the hospital imports evaluation data from the various sources (described above) on a monthly basis into a central repository or database. This process has increased the hospital’s ability to report on many more aspects of the program and allows for more comprehensive evaluation of the program.
Context of the InnovationUMass Memorial Medical Center is a 781-bed private, nonprofit institution that is part of UMass Memorial Health Care, the health system affiliated with the University of Massachusetts Medical School. The medical center, which operates 2 teaching hospitals, 2 satellite hospitals, and 50 ambulatory clinics, serves Worcester County, MA, a highly multi-ethnic and multicultural area with more than 750,000 residents who speak roughly 85 languages at home.12 The impetus for this program came from the growing number of immigrants in the community with limited English proficiency. The program, led by the director of Language Services with support from two physicians and a senior researcher, began as part of the Robert Wood Johnson Foundation's National Language Services Network (called Speaking Together), an 18-month collaborative launched in 2006 to test various measures of the effectiveness of interpreter services. UMass Memorial Medical Center was 1 of 10 hospitals to participate in the program.
ResultsThe program reduced patient waiting time for an interpreter, increased the number of languages in which services are available and the number of interpretations provided, and reduced length of stay (LOS) for patients with limited English proficiency. An ongoing demonstration program will evaluate the program's impact on hospital readmissions.
Moderate: The evidence consists of pre- and post-implementation comparisons of key measures related to interpreter services, including patient waiting times, available languages, and number of interpretations provided. The evidence also includes a retrospective analysis comparing average length of stay for patients with limited English proficiency who receive interpreter services with a similar group not receiving such services.
- Shorter waiting time for services: Before 2007, approximately 50 percent of patients who needed an interpreter waited 15 minutes or less. By fiscal year 2009 (October 2008 to September 2009), 86 percent of patients waited 15 minutes or less.
- More languages available: The number of languages in which interpreter services are available has nearly doubled, from 51 in 2007 to 136 in 2013. The bulk of the increase occurred in languages not commonly spoken in the hospital's service area.
- More interpretations: The total number of interpretations more than doubled, from 59,630 in fiscal year 2006 to more than 135,838 in fiscal year 2012. The number of telephonic interpretations increased by 500 percent, from 6,336 in fiscal year 2007 to 32,141 in fiscal year 2010, while the number of interpretations provided by onsite night-shift staff rose by more than 200 percent between fiscal years 2006 and 2010.
- Lower LOS and less likely readmission: LOS for patients with limited English proficiency averaged 1.3 fewer days for those receiving interpreter services than for similar patients not receiving such services. Similarly, patients receiving interpreter services at admission and/or discharge were less likely to be readmitted to the hospital within 30 days than similar patients who received no interpreter services (updated April 2013).13
- More prescheduled requests: Before implementation of the inpatient door posters, all inpatient interpreter requests were for same-day interpretation. By September 2009, prescheduled requests accounted for 5 percent of all requests; the department's goal is to increase this figure to 20 percent.
- Full adherence with registration and documentation: All patients have their preferred language and need for an interpreter collected at registration.
Planning and Development ProcessKey steps included the following:
- Committee formation: In 2005, the Medical Executive Committee approved the formation of an ad hoc quality improvement committee to increase the effectiveness and quality of communication with limited English proficiency and deaf or hard-of-hearing patients. The proposal was submitted by the vice chair for community health from the Department of Family Medicine and Community Health, who has served as a physician champion for the Language Services Department.
- Training on importance of providing quality services: The director of Language Services gave presentations to staff on the importance of quality in general and on how the quality of interpreter services relates to the overall goals of the organization. Subsequently, the director assigned a quality lead interpreter to conduct specific training regarding particular quality improvement strategies, such as how to complete and submit the encounter form.
- Adjusting data collection and information systems: The director of Language Services met with representatives of the Information Technology Department, registration staff, and interpreter services to determine effective strategies for collecting needed information at the point of registration. The hospital's Information Technology Department made adjustments to the existing information system to allow for collection of this data.
- Assigning quality teams: The director of Language Services assigned staff interpreters to different quality-oriented teams. (Interpreters work on these teams in addition to performing regular duties.) For example, a scheduling team monitors the scheduling process and looks for errors, an education/mentoring team provides mentoring for new interpreters, and a quality team meets to brainstorm new ideas for quality improvement.
- Selecting vendor for telephone-based services: The Language Services Department sent out a "request for proposals" to vendors, reviewed the submitted proposals, and selected a vendor.
- Using rapid-cycle improvement to test new ideas: A rapid-cycle improvement process guides the ongoing development and testing of improvement strategies, such as the encounter form and staffing of the night shift.
- Expanding services and pursuing ongoing quality improvement: The hospital has pursued ongoing quality improvement efforts and activities such as expanding the number of languages offered and use of telephonic interpretation for inpatient services, developing a daily language error report (measuring registration staff errors in language selection) and an electronic calendar that allows interpreters to submit availability, monitoring which eligible patients do not get interpretation services (and why) and improving training for outpatient schedulers regarding interpretation scheduling.
- Renegotiating contract: Information provided in March 2011 indicated that the hospital renegotiated its contracts for telephonic interpreters based on growth in demand.
Resources Used and Skills Needed
- Staffing: The Language Services Department has approximately 34.24 full-time equivalent staff, including a director, a coordinator of education and training, administrative support staff, dispatchers, 47 staff interpreters (both part time and per diem), 20 trained onsite interpreters under contract, and telephone interpreters under contract through a vendor.
- Costs: The Language Services Department annual budget is approximately $2.5 million. The cost of the quality improvement initiatives that make up this program varies. For example, adding telephonic interpretation services proved to be costly (averaging roughly $20 per encounter), whereas providing mentoring and developing and using the encounter form cost relatively little. Even expensive programs, such as telephone-based interpretation, should be considered within the context of the larger organizational impact, as such services can reduce expensive care delays and medical errors.
Funding SourcesRobert Wood Johnson Foundation; UMass Memorial Medical Center
Tools and Other ResourcesGlossaries of medical terms developed by the hospital can be obtained by contacting the program developer.
Getting Started with This Innovation
- Make business case to secure leadership buy-in: For example, although providing interpretation services at registration can be costly, it allows for the collection of complete, accurate information about insurance coverage, greatly increasing the odds that the hospital will receive appropriate reimbursement.
- Use organizational resources: Identify and connect with medical staff willing to serve as the program's physician champions. System leaders will listen to members of the medical staff, particularly if needs can be articulated as quality issues. In academic institutions, partnering with researchers committed to overcoming health care disparities can be helpful in designing data collection systems that help to articulate the upfront need and document ongoing improvement.
- Train staff about importance of quality: By providing training to staff on the importance of incorporating principles of quality into daily work, the Language Services Department changed its culture to focus on quality measurement and improvement. Information provided in April 2013 indicates that integrating structured and disciplined quality improvement methodologies such as LEAN and A3 (enhanced PDSA methodology) into the fabric of the Language Services Department operations has gained the respect of clinicians and staff, and it has raised awareness of the need to meet language preferences. Currently, 70 percent of Language Services staff have attended LEAN trainings and the hospital continues to use this methodology to study and improve current program operations.
- Simplify communications: Initially, the hospital used two posters to display information about a patient's language needs—one informing providers of these needs and a second describing how to access an interpreter. Because hanging both posters proved cumbersome for staff, program leaders combined them into one poster, thus enhancing compliance.
- Use mentors: A mentoring program leverages the experience of senior interpreters and helps improve the performance of new interpreters.
- Use electronic systems: Information provided in April 2013 indicates that moving toward an electronic, centralized system (as opposed to paper based) saves time and increases productivity. Electronic requests help dispatchers and schedulers decrease waiting time for interpreter requests. Centralizing program data also allows for more comprehensive reporting, which helps focus quality improvement efforts.
Sustaining This Innovation
- Measure program impact: Measuring the program's impact on the organizational bottom line can help ensure ongoing management support.
- Assess quality of telephone-based, contract interpreters: Providers will be more likely to continue to use these interpreters if they know that their quality has been assessed and confirmed.
- Continue monitoring activities: Ongoing monitoring of the accessibility and quality of interpreter services can be crucial to ensuring sustainability and generating ideas for ongoing improvement.
- Constantly reevaluate demand: Program developers should constantly reevaluate the demand for services so that interpreter capacity can be adjusted accordingly.
- Renegotiate contracts to maximize cost-efficiency: Increasing interpreter capacity can be costly. To control these costs, renegotiate contracts based on a sliding scale, with a lower hourly flat rate as volume increases. Include volume from smaller hospitals in the contract to ensure that these organizations continue to have timely access to low-cost interpreter services.
Contact the InnovatorConnie Camelo
Director of Interpreter Services
UMass Memorial Health Care
55 Lake Avenue North
Worcester, MA 01655
UMass Memorial Health Care
55 Lake Avenue North
Worcester, MA 01655
Innovator DisclosuresMs. Camelo and Mr. Timm have not indicated whether they have financial interests or business or professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesRobert Wood Johnson Foundation. Initial and ongoing evaluation of interpreters. June 4, 2008. Available at: http://www.rwjf.org/pr/product.jsp?id=30593.
Robert Wood Johnson Foundation. Establishing an assessment and grievance process to evaluate telephonic interpretation. June 4, 2008. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2008/06/quality-improvement-initiative.html.
Weinick RM, Krauss NA. Racial/ethnic differences in children's access to care. Am J Public Health. 2000;90(11):1771-4. [PubMed]
Woloshin S, Schwartz LM, Katz SJ, et al. Is language a barrier to the use of preventive services? J Gen Intern Med. 1997;12(8):472-7. [PubMed]
Fiscella K, Franks P, Doescher MP, et al. Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care. 2002;40(1):52-9. [PubMed]
6 Andrulis D, Goodman N, Pryor N. What a difference an interpreter can make: health care experiences of uninsured with limited English proficiency. Boston, MA: The Access Project; April 2003.
David RA, Rhee M. The impact of language as a barrier to effective health care in an underserved urban Hispanic community. Mt Sinai J Med. 1998;65(5-6):393-7. [PubMed]
Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255-99. [PubMed]
Flores G, Rabke-Verani J, Pine W, et al. The importance of cultural and linguistic issues in the emergency care of children. Pediatr Emerg Care. 2002;18(4):271-84. [PubMed]
Hampers LC, McNulty JE. Professional interpreters and bilingual physicians in a pediatric emergency department: effect on resource utilization. Arch Pediatr Adolesc Med. 2002;156(11):1108-13. [PubMed]
12 Information provided by Connie Camelo.
Lindholm M, Hargraves JL, Ferguson WJ, et al. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012;27(10):1294-9. Epub 2012 Apr 18. [PubMed]
|Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.|
Original publication: March 31, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: April 02, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.