BACKGROUND

Communication is fundamental to high-quality health care. Despite federal requirements to provide interpreters and growing evidence favoring the benefits of interpreter use, providers’ use of interpreters remains suboptimal. In acute care settings, where decisions need to be made rapidly on the basis of changing clinical circumstances, this has proven to be challenging.

METHODS

We designed a quality improvement project using the model for improvement methodology for patients admitted to the pediatric hospital medicine service. A multidisciplinary team developed interventions focused on provider education and leveraging health information technology (IT). We used health IT to improve the identification of families with limited English proficiency, improve access to various modalities of interpreting, standardize workflow to request face-to-face (F2F) interpreters, and create a designated place in the electronic health record for interpreter use documentation. The use of all forms (telephone, video, and F2F) of interpreter service, documentation of interpreter uses, and F2F interpreter overload were tracked monthly for 3 years.

RESULTS

The baseline use of interpreter services for the pediatric hospital medicine inpatient service was 64%. After starting the project, the use of interpreter service increased to 97% and has sustained for more than a year since the project’s completion. The use of F2F interpreters also increased from a baseline of 20% to 54% post intervention.

CONCLUSIONS

We successfully achieved and sustained our goals of improving interpreter use through supportive leadership and a multidisciplinary approach using quality improvement methodology. Future efforts should be focused on defining and standardizing metrics for families with limited English proficiency across institutions and using health IT to improve care.

According to the 2017 American Community Survey report, 22% of the US population speaks a language other than English at home.1  This includes native-born US residents and documented and undocumented immigrants. Title VI of the US Civil Rights Act2  of 1964 is a federal law that requires partially or fully federal-funded institutions, including hospitals and medical facilities, to provide free and competent interpreters and translation services to patients and families with limited English proficiency (LEP). In 2010, The Joint Commission set new and revised standards for patient-centered communication as part of its project to advance effective communication, cultural competence, and patient- and family-centered care.3  No longer considered to be simply a patient’s right, effective and culturally appropriate care is now considered an essential aspect of quality care and patient safety.4 

Language barriers between providers and patients are known to decrease health care quality and increase the risk of serious medical events during hospitalization.5,6  They are also associated with misdiagnosis, inappropriate treatment, and the need for repeat visits and other costly outcomes.711  Professional interpreter services are currently available via various modalities, including in person or face-to-face (F2F), over the phone, and remote video interpreting. Families with LEP, defined as families who prefer to communicate about their medical care in a language other than English,12  have indicated that they prefer F2F interpretation as opposed to telephone interpretation.13  Medical providers and medical interpreters also prefer F2F interpretation.13,14  Although F2F is the preferred modality, the use of any form of interpreter service is associated with fewer errors and is superior to either an informally assigned ad hoc interpreter or no interpreter.15 

Our institution is a freestanding children’s hospital system, located in a metropolitan area in the Midwest, with ≥400 beds and ∼13 000 inpatient admissions per year. The division of pediatric hospital medicine (PHM) admits >4000 patients annually and is the largest single admitting service. Data reveal that 5% to 8% of people living in the surrounding area are born outside the United States, with 7% speaking a language other than English at home. Of the 7% who speak a language other than English, 52% reported speaking English “less than very well.”16,17  Before this project, there was no standardized institutional process for requesting or documenting interpreter use for inpatient families with LEP. Audits suggest that the baseline interpreter use was 64% and that F2F interpreter use was 20%.

In January 2018, a quality improvement (QI) project was initiated to improve inpatient interpreter use within the PHM division. The aims of the project were as follows:

  1. to increase the use of any form of interpreters from 64% to 80% by the end of 2019; and

  2. to increase the use of F2F interpreters from 20% to 50% by the end of 2019.

The PHM division at our institution admits patients ranging from 0 to 25 years of age. The PHM service has 4 resident teams, each composed of 4 to 5 residents, 1 fellow, 1 to 2 medical students, and 1 attending. In addition, there is a service that includes 2 nurse practitioners (NPs) and an attending hospitalist. The NP team carries fewer patients than resident teams and covers the consultation and surgical comanagement service. Each team has a designated rounding time between 8:30 am and 12 pm, lasting anywhere from 60 to 120 minutes. Family-centered rounds are performed with interns, residents, nurses, and NPs, who present the patients in the hospital room.

Approximately 3% of admitted patients at our institution prefer speaking a language other than English. Spanish is the most commonly spoken language (34%), followed by Nepali, Arabic, and Karen (31%, 8%, and 7%, respectively). Other languages are spoken <5% of the time. Our institution has a language access division (LAD) that provides interpretive services for >240 languages via audio and video interpreters available 24 hours a day. The F2F interpreter service is available Monday through Friday between 8:00 am and 4:30 pm. On weekends and after hours, the F2F interpreter service is available only in emergency situations. F2F interpreters are available in 12 languages: Arabic, Burmese, Chinese, French, Karen, Kinyarwanda, Mandarin, Nepali, Russian, Spanish, Swahili, and American Sign Language.

Despite the availability of these resources, there were multiple barriers to their use. The audio and video devices were difficult to locate on the units, and there was no standard process to request the F2F interpreters. Teams often used ad hoc interpreters, such as family members, friends, and medical staff (including residents and nurses), without appropriate medical interpreter training and certification. There was no designated place in the electronic health record (EHR) to document the use of interpreters.

The project was proposed by the residents and was supported by the division of PHM. A multidisciplinary QI team was formed and included hospitalists, residents, LAD staff, nurses, and F2F interpreters. The model for improvement was selected as the improvement methodology. The study was reviewed and deemed exempt from institutional review board oversight by our hospital’s institutional review board.

After the initial discussion between QI team members, a process map was generated, and key risk areas were identified. A key driver diagram (Fig 1) was created, and the team designed interventions targeting the key drivers.

FIGURE 1

Key driver diagram: improving interpreter use for families with LEP in the PHM service.

FIGURE 1

Key driver diagram: improving interpreter use for families with LEP in the PHM service.

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After the baseline data collection, we informed our project to various committees in our institution, including leaders from the patient experience committee, who oversaw the LAD; the regulatory and accreditation committee; the clinical effectiveness committee; and the residency program. The timing of our project also mattered because we were due for an accreditation visit for our institution around the same time. Our project aligned with the institutional needs; thus, we obtained visible support from high-level physician and nursing leadership, including resource allocation and prioritization of EHR changes.

An educational session was provided to the residents after the baseline data collection period in January 2018. Residents were chosen because they were the first physicians to contact the patient after arrival to the inpatient unit. The educational session included a 30-minute interactive discussion led by our LAD manager. The discussion included Joint Commission standards, resources available for interpretation within the organization, and practice with case-based scenarios. In addition, monthly e-mail reminders were sent out to residents on the inpatient unit during their first week of service. This e-mail included how to identify families with LEP, request interpreters, and appropriately document interpreter use in the EHR.

Hospitalists and nursing staff received similar educational sessions during monthly division and staff meetings. Feedback was obtained directly during these meetings to discuss ongoing issues and identify problem areas. Secondarily, hospitalist buy-in was further strengthened by leveraging a quality-based physician incentive plan, which was already an established program at our institution. The physician incentive plan is an arrangement to pay a physician or physician group for improving quality metrics designed to enhance value for patients and families. A customized online module for nursing staff was created to review annually as part of mandatory nursing education. This module included Joint Commission requirements, resources within the institution, information on how to request interpreter services, and appropriate EHR documentation. Clinical nurse leaders and educators worked closely with the QI team to disseminate the interventions to bedside nurses.

Identification of Patients and Families With LEP

For our initiative, we defined patients and families with LEP as any who self-reported their preferred language as anything other than English. On the basis of common routes for admission to the PHM service, education efforts targeted registration staff of emergency and admitting divisions to assist in identifying families with LEP. Language identification cards and posters and video and audio devices were made available to identify the language and communication needs of families with LEP. Registration staff in these areas asked if there was a preferred language and if an interpreter was needed and documented it in the EHR. The medical team verified this after patients and families arrived at the inpatient unit.

The LAD also created a daily report of families with LEP from the EHR. This list was generated every morning by the LAD, so the F2F interpreters were aware of the potential requests. In addition, if an interpreter was not requested, the interpreters could call the medical team and ask if they could be of assistance. This created 2-way communication between the medical team and LAD, ensuring that families with LEP could access F2F interpreters.

Appropriate Documentation

The QI team immediately noticed that there was no designated place in the EHR for documenting the use of interpreter services. Interpreter use was documented inconsistently in history and physical notes, progress notes, and nursing flow sheets. The team worked with the health information technology (IT) team to create a language access navigator (LAN), a designated place in the EHR, to document interpreter use. The LAN includes the language used, the type of interpreter service (video, audio, or F2F), the time of interpreter use, and the reason for use (Fig 2). The LAN was embedded within the admission, rounding, and discharge navigator, a series of sections in the EHR to support the clinical workflow. This was introduced organization-wide in April 2018 and available to physicians, nursing staff, and ancillary staff after pilot testing. The improvement team also created “dot phrases,” which are prepopulated macros that start with a period and bring specific linked content. In this case, “.interpreter” brought information from the LAN into the initial history and physical note or daily progress note so that the work was not duplicated. This facilitated short- and long-term performance monitoring, eliminating the need for manual chart audit for interpreter compliance.

FIGURE 2

Screenshot of the LAN in our EHR. ©2020 Epic Systems Corporation. IP, internet protocol; LDA, line, drain, airway; MAR, medication administration record; TTY, teletypewriter; Tx, treatment.

FIGURE 2

Screenshot of the LAN in our EHR. ©2020 Epic Systems Corporation. IP, internet protocol; LDA, line, drain, airway; MAR, medication administration record; TTY, teletypewriter; Tx, treatment.

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Automated Notification to the LAD

Starting in January 2019, the QI team focused on improving the use of the F2F interpreter service. An electronic consultation order was created in the EHR in April 2019 to request F2F interpreters. The order included the requested language, the day and time F2F interpretation was needed (range of 2-hour block; eg, between 8 and 10 am or 12 and 2 pm), and a call-back number for confirmation. Once the order was signed, an immediate request was sent to the LAD, flagging a need for an F2F interpreter. Multiple plan-do-study-act cycles were done within the PHM division before finalization of the order request in the EHR. The final order could be placed at any time by the medical team, including days in advance, thus eliminating the need for last-minute calls. A standard workflow was created in July 2019 for requesting an F2F interpreter for admitted patients (see Supplemental Fig 5). This was posted on the hospital’s Web page and distributed to all PHM providers.

Improving Infrastructure

In September 2018, the QI team audited the availability of audio and video devices on the clinical units. The team found that the inpatient units on the same floor shared a single video device and that there was no designated storage location. The LAD purchased additional devices, and each unit was provided with their own device for audio and/or video access. Similarly, a storage space for devices was designated at all units. Nursing stations at all inpatient units displayed posters revealing how to access the audio and video interpreters.

Outcome Measure

The primary measure of our study was the monthly percentage of families with LEP with at least 1 use of interpreter services (telephone, video or F2F) per admission to the PHM service. A detailed chart review was done to find documentation of interpreter use in the EHR, including admission notes, progress notes, the discharge summary, and flow sheets. If no documentation was noted, a query inquiring about the use of interpreter services was sent out to the discharging hospitalist. A chart was considered compliant with interpreter use if the physician answered that an interpreter was used.

Our secondary measure was the monthly percentage of F2F interpreter use for languages provided by our LAD for families with LEP who were admitted. This was measured similarly as the primary metric.

Process Measure

Our process measure was the documentation of interpreter use in the LAN in the EHR. An automatic report was generated monthly via the EHR and sent to QI team members. These data were only available after the LAN intervention was completed.

Balancing Measure

Our balancing measure was to assess if inpatient F2F interpreter requests would overwhelm the interpreters. Interpreter overload was defined as ≥3 60-minute blocks of inpatient requests per interpreter per day. The F2F interpreters cover both our inpatient and outpatient services. We did not want an untoward effect of providers not being able to use F2F interpreters in outpatient services. We tracked the inpatient use of Spanish and Nepali (the 2 most commonly used languages) F2F interpreter services bimonthly.

The p-chart, a statistical process control chart using the binomial distribution, was used to assess the impact of improvement efforts for both the primary and secondary aims. A run of ≥8 points in a row above or below the centerline was considered a shift. A Wilcoxon rank test by using SAS 9.4 (SAS Institute, Inc, Cary, NC) was used to calculate bimonthly F2F interpreter use.

The baseline period was from August 2017 to December 2017. Sixty-four patients whose preferred language was not English were admitted within this period and needed an interpreter. Among these 64 patients, at least 1 form of interpreter service was used in 41 patients (64%). Audio, video, and F2F interpreter services were used in 7.3% (n = 3), 61% (n = 25), and 24.4% (n = 10) of patients, respectively. In the remaining 3 patients, it was documented that an interpreter was used, but the type of interpreter was not specified. For F2F interpreter use, only families who spoke the 12 languages for which F2F interpreter services were available in our institution were included in the denominator. Table 1 reveals the number of patients included in the study and their preferred languages.

TABLE 1

Number of Patient Encounters and Their Preferred Languages in Various Phases of the Study

CharacteristicBaselineInterventionPostintervention
Total patient encounters, n 64 251 93 
Preferred language, n (%)    
 Spanish 21 (33) 76 (30) 37 (40) 
 Nepali 18 (28) 113 (45) 23 (25) 
 Karen 7 (11) 15 (6) 11 (12) 
 Arabic 12 (19) 18 (7) 4 (4) 
 Pashto 0 (0) 0 (0) 4 (4) 
 Others 6 (9) 28 (11) 14 (15) 
CharacteristicBaselineInterventionPostintervention
Total patient encounters, n 64 251 93 
Preferred language, n (%)    
 Spanish 21 (33) 76 (30) 37 (40) 
 Nepali 18 (28) 113 (45) 23 (25) 
 Karen 7 (11) 15 (6) 11 (12) 
 Arabic 12 (19) 18 (7) 4 (4) 
 Pashto 0 (0) 0 (0) 4 (4) 
 Others 6 (9) 28 (11) 14 (15) 

Percentage decimals are rounded to the nearest whole number.

Our intervention period was January 2018 to June 2019. There was an immediate improvement in our interpreter usage. Our mean use of interpreters increased from a baseline of 64% to 81% and then to 98% (Fig 3). For F2F interpreter use, there was a shift from 20% to 36% and then to 54% (Fig 4). Our process measures also improved with documented interpreter use in the LAN from 69% to 98%. We continued manual chart review after introducing the LAN to validate our process measure and did not find any discrepancies in the interpreter use documentation. We noted that only 1.2% (4 of 344) of total encounters in the intervention and postintervention phases did not have any interpreter use documented, and interpreter use had to be confirmed after direct communication with the physician. The monthly median F2F interpreter use increased from 8.5 to 24.0 and from 4.5 to 10.5 (P = .01 and .02) for Spanish and Nepali, respectively. On the basis of the definition of interpreter overload, as defined by the LAD team (≥3 60-minute blocks of inpatient requests per interpreter per day), this increase was not considered an overload.

FIGURE 3

Control chart revealing the percentages of all forms of interpreter use (August 2017 to December 2019). PIP, physician incentive plan.

FIGURE 3

Control chart revealing the percentages of all forms of interpreter use (August 2017 to December 2019). PIP, physician incentive plan.

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FIGURE 4

Control chart revealing the percentages of F2F interpreter use (August 2017 to December 2019). PIP, physician incentive plan.

FIGURE 4

Control chart revealing the percentages of F2F interpreter use (August 2017 to December 2019). PIP, physician incentive plan.

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The postintervention data period was defined as July 2019 to December 2019. No new interventions were added, and data were monitored to follow the trends. The data were shared with PHM attending physicians during the QI meeting. The mean use of interpreter services, LAN use, and F2F interpreter use remained at 97%, 98%, and 54%, respectively, all above our goal.

The Institute of Medicine defined 6 aims of high-quality health care. In equitable care, it is recognized that all individuals should be supported in achieving the best health outcomes, regardless of differences, including race, ethnicity, and any other demographic characteristic. Although efforts to realize equitable health care require improvement on many fronts, enhanced access and use of interpretive services are essential. This QI project has revealed a successful and necessary increase in the use and documentation of interpreter services for all families with LEP admitted to the PHM service. Continuous monitoring reveals that the improvement has sustained well after 1 year since project completion. This work is consistent with other literature that proves that well-planned improvement science study can improve the use of interpreter services for families with LEP.18,19  Previous surveys have revealed that lack of knowledge is not a critical factor affecting interpreter use in patients with LEP; instead, the technical and adaptive challenges, including time and workflow constraints and a supply-demand mismatch, played a higher impact.2022  Our study adds to this knowledge that by using a multidisciplinary group to remove workflow barriers and providing easy access to interpreters, a sustainable change is achievable.

Our project’s key strength was the involvement of a multidisciplinary team that included nursing staff, residents, QI educators, the LAD, and the interpreters themselves. One of our most successful interventions was obtaining support for workflow changes from nursing. Although the physicians may be responsible for medical decisions, nurses perform the majority of bedside interactions. We noticed that once the nursing staff was on board, the video devices were already placed in the rooms for families with LEP when physicians arrived, thus making it easier to use the device. The purposeful embedment of the LAN in the EHR and the addition of real-time notification to the LAD via consultation order overcame the technological challenge of the fragmented workflow. Knowing the number of families with LEP in the hospital every day helped the F2F interpreters be better prepared to provide needed services. This bidirectional communication between the medical team and the LAD fostered mutual respect and understanding of each other’s workflow. Without the LAD and the interpreters’ support, improving and sustaining interpreter use would not be possible.

Our improvement project uncovered multiple challenges. Correctly identifying families with LEP is challenging. We defined preferred language as the “language you prefer to learn in”; however, this does not identify the presence of a language barrier or the need for interpretive services. In addition, trying to determine whose English proficiency needs to be documented in the EHR (eg, the mother may be proficient in English, but the father may not be and may still require an interpreter) is a struggle because this may change depending on who is at the bedside. All missed cases of usage and/or documentation in our project were because of this discordance. Once the consultation order and standard workflow were in place, the LAD faced the challenge of coordinating and ensuring that the F2F interpreter was available within a few hours. Unlike the outpatient department, in which interpreter appointments are scheduled weeks to months in advance, inpatient interpreter needs are more challenging to predict. Taking time consideration in account for F2F interpreters, a 2-hour notification was considered reasonable by both teams to obtain an F2F interpreter. At the start of our project, both providers and LAD personnel thought it was not their responsibility to arrange for interpreter services. With thoughtful leadership involvement and F2F discussions between teams, this barrier was overcome, with both sides assuming equal responsibility. The creation of a standard workflow helped maintain accountability and consistency. As with most QI projects, opportunity costs need to be considered specifically when buying additional devices and changing EHR designs. However, the benefits of these, that is, the ability to communicate with families with LEP in their preferred language, was considered worth the substantial investments.

Our improvement project has several limitations. First, our study was focused on improving use of the interpreter service and its documentation, a proxy measure for the true patient outcome measure. An optimal patient outcome measure would be decreased adverse effects of communication failures or improved understanding of discharge instructions. Second, we defined a single interaction with an interpreter as a compliant encounter. There is no national benchmark related to the quality of care in language services on how many interactions there should be or how long an interaction should be to be considered compliant. We recognize that the single use of interpreters during hospitalization may not be adequate to achieve optimal patient care. Our study also had a vigorous process to measure interpreter use in the intervention phase compared with the baseline phase, including the use of the LAN and queries sent to attending physicians after discharge, which could reflect measurement bias. We attempted to compensate for this by tracking the number of compliant charts identified by querying the physicians. The low number of encounters identified by queries alone (4 encounters throughout the study period) can be a proxy of an actual increase in interpreter use and not merely the documentation of use. Lastly, our study was conducted at a single institution with a dedicated LAD, and thus the results may not be generalizable to other institutions.

In combination with supportive leadership involvement, education, and improving infrastructure, health IT can be a novel approach to improving the use of interpreter services in families with LEP. Improvement in all forms of interpretive services, including the F2F interpreter service, was achieved and sustained by using QI methodology. Future efforts should be focused on defining and standardizing metrics for families with LEP across institutions and using IT to remove barriers and provide easy access to interpreter services to improve care.

FUNDING: No external funding.

Drs Rajbhandari and Keith conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Gunkelman, Ms Braidy, and Ms Smith coordinated interventions and critically reviewed the manuscript; and all authors approved the final manuscript as submitted.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.