SummaryUnder a program known as “Mind the Gap,” Children’s Hospital Central California provides non–English-speaking and low-literacy patients and their families with a recording of their specific discharge instructions in their native language. Interpreters simultaneously record discharge instructions during translation, and patients and family members can access a password-protected telephone mailbox to hear the recording as needed for up to 2 weeks after discharge. The program has been used by a higher-than-expected number of patients and family members, has reduced gaps in comprehension, and has generated high levels of patient/family satisfaction.Moderate: The evidence consists of an analysis of use of the system in a pilot study of 132 patients/families given access to the recordings after outpatient surgery; a comparison of comprehension 3 days after discharge among two groups of limited English proficiency patients—one with access to the recordings and a second without access; and anecdotal feedback from patients and families.
Developing OrganizationsChildren's Hospital Central California
Date First Implemented2009
Race and Ethnicity > Asian; Age > Child (6-12 years); Vulnerable Populations > Children; Race and Ethnicity > Hispanic/Latino-Latina; Vulnerable Populations > Illiterate/Low-literate; Immigrants; Age > Infant (1-23 months); Vulnerable Populations > Non-English speaking/Limited English proficiency; Age > Preschooler (2-5 years); Vulnerable Populations > Racial minorities
Problem AddressedNearly 90 percent of adults lack adequate health literacy—that is, the capacity to obtain, process, and understand basic health information and services so as to make appropriate health decisions1—thus putting them at increased risk of poor medical outcomes.2 Poor health literacy can be especially problematic among patients with limited English proficiency (LEP), who may not be able to read or understand instructions provided at hospital discharge.
- Limited health literacy among adults: According to the U.S. Department of Health and Human Services, only 12 percent of adults have proficient health literacy skills.3
- Increased risk of poor outcomes: Patients who do not understand medical information face an increased risk of unnecessary testing, medication errors, emergency department visits, hospitalization, and suboptimal chronic disease self-management.2 Poor health literacy becomes particularly risky at hospital discharge, as many readmissions occur because hospitalized patients and their family members do not adequately understand postdischarge care needs, including complicated medication regimens and the need for followup care from different providers.4
- Particularly problematic for LEP patients: Communication barriers impede the understanding of and adherence to treatment plans and therapies among LEP patients, thereby increasing the risk of suboptimal outcomes.5 LEP patients may not understand discharge instructions and may not be able to read the written instructions provided to them for later reference. A study conducted at Children’s Hospital Central California found that only 62 percent of patients understood which symptoms/changes would prompt a return to the hospital or a call to the physician; 75 percent understood the necessary steps for wound care; 83 percent understood the medication regimen; and 83 percent knew the date of their followup appointment.6
Description of the Innovative ActivityUnder a program known as “Mind the Gap,” Children’s Hospital Central California provides non–English-speaking and low-literacy patients and their families with a recording of their specific discharge instructions in their native language (Spanish, Hmong, or Mixteco-Bajo, an indigenous language unique to the hospital’s geographic area). Interpreters simultaneously record discharge instructions during translation, and patients and family members can access a password-protected telephone mailbox to hear the recording as needed for up to 2 weeks after discharge. Key elements of the program include the following:
- Interpreter recording of discharge instructions: As a standard step in the discharge process, the nurse calls an interpreter to record a translated version of the discharge instructions for LEP families in their native language. To ensure efficiency, the nurse prepares and completes all of the discharge information in advance of the interpreter's arrival. Although the nurse provides oral and written discharge instructions to the family, the interpreter translates the instructions for the patient/family while simultaneously speaking into a headset connected to a recording device via the interpreter’s cell phone. The discharge instructions typically include diagnosis-specific information related to self-management (e.g., recommended diet, physical activity, wound care), needed followup care and appointments, and the medication regimen (including instructions on how to adhere to it), along with the answers to any questions addressed during the discharge process. The recording also includes a reminder to patients and families to seek clarification from a provider if they have any questions after discharge. The recorded translation is then automatically uploaded to a telephone-based system that provides password-protected mailboxes.
- Patient/family education on accessing instructions: The interpreter demonstrates how to access the telephone line and provides the family with a refrigerator magnet that lists the toll-free telephone number and mailbox password.
- As-needed access for 2 weeks: In addition to receiving written instructions in their own language for reference, patients and families can listen to the recording of the discharge instructions by using the toll-free telephone number and password; the recording remains available to them at any time for up to 2 weeks following discharge. Patients and families can share the telephone number and password information with other family members and care providers who assist with their care, which can further promote understanding of the instructions.
References/Related ArticlesTackling Health Literacy to Improve Patient Care. Children’s Hospital Central California Press Room. September 22, 2009. Available at: http://www.childrenscentralcal.org/PressRoom/HospitalNews/Pages/HealthLit.aspx
Lehman S, Kaur S, Ave A, et al. Mind the Gap: A Health Literacy Initiative Aimed at Improving Patient Safety. Unpublished manuscript.
Contact the InnovatorSamuel Lehman, MD
Medical Director of Patient Safety
Associate Medical Director, Pediatric Intensive Care Unit
Children’s Hospital Central California
9300 Valley Children’s Place
Madera, CA 93636
Innovator DisclosuresDr. Lehman has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe program has been used by a higher-than-expected number of patients and family members, has reduced gaps in comprehension, and has generated high levels of patient/family satisfaction.
Moderate: The evidence consists of an analysis of use of the system in a pilot study of 132 patients/families given access to the recordings after outpatient surgery; a comparison of comprehension 3 days after discharge among two groups of limited English proficiency patients—one with access to the recordings and a second without access; and anecdotal feedback from patients and families.
- Higher-than-expected use of recorded instructions: Approximately 30 percent of patients/families who participated in a 2009 pilot study accessed the recorded discharge instructions, typically more than once. Program developers expected fewer patients to do so, because the study included some patients without low health literacy and focused on outpatient surgery cases that typically involve relatively simple discharge instructions. Program developers believe that this high level of usage indicates that LEP patients/families likely did not fully understand or remember the instructions at discharge, thus validating the need for the program.
- Fewer gaps in comprehension: LEP patients given access to the recordings exhibited fewer and smaller gaps in comprehension than did a group of similar LEP patients without access to them (data unavailable). This analysis covered five areas of comprehension—diet, activity, wound care, medications, and followup care—with measurements taken at discharge and 3 days later.
- High patient satisfaction: Anecdotal feedback has revealed high levels of satisfaction among both patients and family members, who have expressed appreciation for having access to audible information in their native language.
Context of the InnovationChildren’s Hospital Central California, a 348-bed pediatric tertiary care institution located in Madera, CA, handles approximately 13,000 admissions each year. The hospital is the only pediatric inpatient facility serving 1.2 million children living in the Central Valley of California, a geographic area extending north to Sacramento and south to Bakersfield (approximately 35,000 square miles) that is home to a highly diverse, largely migrant population. Latinos represent approximately 40 percent of the population in the Central Valley, which is also home to approximately 50,000 Hmong (roughly half the total Hmong population in the country). Approximately 14 percent of adults living in the region have a college degree, and 40 percent speak a language other than English at home. Given the low socioeconomic status and ethnic diversity of the patient population, administrators and clinicians at Children’s Hospital Central Valley became concerned about health literacy, particularly that written information might not be understood. For example, the Hmong’s written language was created only recently, and the population still relies heavily on oral communication.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Securing senior leadership approval: The "Mind the Gap" project was proposed by Dr. Samuel Lehman, Medical Director of Patient Safety. Senior leaders readily approved the project, given the organization’s heavy focus on patient safety.
- Forming task force: Program leaders developed a task force of individuals that included staff that would be affected by the proposed initiative and those who could serve as content experts, including representatives from interpreter services, nursing, clinical education, and information technology. The task force met throughout the fall of 2008 to design the initiative.
- Conducting pilot test: The task force selected two units to pilot test the program for 6 months, and then met with unit directors to outline the work process. Unit directors explained the program and the revamped work process to their respective staff.
- Contracting with vendor: Because the hospital’s existing telephone system could not accommodate the needs of the program, the task force identified and contracted with an external vendor that could provide the service.
- Training interpreters: The task force trained the interpreters on how to use the headsets and access the telephone mailboxes.
- Redesigning and expanding program: Since completion of the pilot study, program developers have changed and enhanced the program. Because the program is intended to promote health literacy (not just provide language interpretation), developers are considering how to better serve English-speaking patients with low health literacy (e.g., by training nurses to use the headsets). They also plan to create videos of discharge instructions for families with infants being discharged from the neonatal intensive care unit; discharge instructions for these patients can be extremely complex and are currently presented in both a written booklet and via visual demonstrations.
Resources Used and Skills Needed
- Staffing: The program does not require new staff, although program developers chose to hire a research assistant to make followup calls to families to administer the assessment tool.
- Costs: Program development and operating costs are minimal, consisting primarily of the cost of the telephonic system (60 mailboxes at approximately $200 per month); headset purchase; design and purchase of refrigerator magnets; research assistant salary; and institutional support (interpreter time, use of telephone, etc.).
Funding SourcesCardinal Health Foundation; Children's Hospital Central California
The “Mind the Gap” program is funded in part by a $25,000 Cardinal Health Patient Safety Grant.
Getting Started with This Innovation
- Communicate with and get input from frontline staff: Program developers should begin communications with frontline staff early so that they can provide input into design and understand how the program will work.
- Anticipate and address impact on work processes: Although the program generally does not have a large impact on the actual time spent by nurses and interpreters, developers should try to anticipate and address potential impediments to workflow. For example, they should design a process that ensures interpreter availability when the patient is ready for discharge so as not to disrupt nurse workflow and patient flow. (The hospital task force had to address this issue, as sometimes, Spanish-speaking patients were ready for discharge before an interpreter could come to the room.) To ensure interpreter efficiency, nurses should have complete discharge information ready and be able to provide instructions in one sitting (without being interrupted to complete other tasks).
- Use existing technology if possible: Ideally, hospitals will be able to use existing telephone systems and mailboxes for the program.
Sustaining This Innovation
- Train widely: Nurses and interpreters need to be periodically trained on how to use the headset and record discharge instructions as part of their natural workflow; this step helps to sustain enthusiasm for the program and expand its impact.
Additional Considerations and Lessons
- Look for related opportunities to improve quality and efficiency: The initiative may reveal opportunities for other efficiency or quality improvements in the discharge planning process. For example, program developers discovered frequent discrepancies between written discharge instructions and those provided orally to patients by nurses. As a result, several units are now improving their discharge processes.
2 National Institute of Medicine Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Nielsen-Bohlman L, Panzer AM, Kindig DA, editors. Washington, DC: National Academies Press; 2004.
5 Ku L. How race/ethnicity, immigration status and language affect health insurance coverage, access to care and quality of care among the low-income population. Washington, DC: Kaiser Family Foundation; August 2003.
6 Lehman S, Kaur S, Ave A, et al. Mind the Gap: A Health Literacy Initiative Aimed at Improving Patient Safety. Unpublished manuscript.
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Service Delivery Innovation Profile
Original publication: September 15, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 05, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 24, 2011.
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.