Problem Addressed

• 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 different languages and served a patient population speaking approximately 85 different languages at home.¹²

Description of the Innovative Activity

• 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 language of choice 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 between the patient, interpreter, and staff member. Forcing functions in the hospital's registration system make identification of a preferred language a "required field." Popup windows with drop-down lists remind staff to verify language information, including primary language, preferred language to receive health care (with 99 languages listed), and whether an interpreter is needed. A free-text field allows staff to enter languages not included in the drop-down list.
  • Posted 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/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.
  • 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: Information provided in March 2011 indicates that interpreters post their weekly availability on an electronic calendar; outpatient schedulers and language services dispatchers refer to the electronic calendar when scheduling interpreters.
    • Automatic scheduling of interpreters for outpatients: Language information automatically transfers from the registration system 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. Schedulers then print the next day's schedules (listing patient name, provider name, and time and location of appointment) to distribute to each interpreter. The Language Services Department sends a standard e-mail 48 hours in advance of appointments to inform providers when the interpretation will be provided and whether the format will be live or by telephone.
    • Same day (unplanned) requests: Dispatchers receive the requests and gather information, including the department making the request, the patient name, the language requested, the time the request is received, and the time the interpreter is dispatched (this information is essential to measure wait time for same-day requests). The dispatchers transfer pertinent information on to color-coded paper (pink for oncampus requests and white for off campus) and dispatch an interpreter. If the expected wait time for a live interpreter is unacceptable to the requester, the dispatcher can immediately connect the caller to a telephone-based interpreter or page a live 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.) Whether a patient receives in-person or telephonic interpretation depends on several factors, including:
    • Availability of interpreter/language: Telephone interpretation is nearly always used for less common languages and for common languages when an in-person interpreter is not available.
    • 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 a live interpreter; for example, schedulers automatically book an inperson interpreter (either someone on staff or a contractor) for those receiving a computed tomography 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: Information provided in March 2011 indicates that interpreters now use internally developed glossaries of medical terms in the 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. Information provided in March 2011 indicates that this previously 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") that 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. Finally, an assigned mentor supports all interpreters, with mentor selection based on their experience and job performance.
    • Vendor evaluation: Language Services Department staff perform real-time evaluations of vendor-provided interpreter services two or three times a week in the 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.

References/Related Articles

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Results

• 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 99 in 2011. The bulk of the increase occurred in languages not commonly spoken in the hospital's service area.
• More interpretations: The total number of interpretations rose by roughly 74 percent, from 59,630 in fiscal year 2006 to more than 104,278 in fiscal year 2010. The number of telephonic interpretations more than doubled, 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: LOS for patients with limited English proficiency averaged 1.3 days less for those receiving interpreter services than for similar patients not receiving such services.
• 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 primary language and need for an interpreter collected at registration.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Committee formation: In 2005, the Medical Executive Committee approved the formation of an ad hoc quality improvement committee to improve the effectiveness and quality of communication with limited English proficiency and deaf/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/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. (They 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: Information provided in March 2011 indicates that 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 (which measures 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 indicates 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 Sources

Tools and Other Resources

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 also 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.
• 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.

Sustaining This Innovation

• Measure program impact: Measuring the program's impact on the organizational bottom line can help to 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: Information provided in March 2011 indicates that ongoing monitoring of the accessibility and quality of interpreter services can be crucial to ensuring sustainability and generating ideas for how to ongoing improvement.
• Constantly reevaluate demand: Information provided in March 2011 indicates that 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.