A quality improvement initiative to streamline and standardize a process to optimize communication between providers and low English proficiency patients/families in the Pediatric Inpatient Unit of Boston Medical Center by incorporating interpreters on all morning rounds
INTRODUCTION: Language barriers between providers and low English proficiency (LEP) families in pediatric hospital care can reduce the quality of care provided to LEP patients/families. Boston Medical Center serves a population with a large LEP patient base. Currently, there is no existing model of care that efficiently and effectively incorporates interpreters on all morning rounds to optimize communication for all patients, especially LEP patients/families. OBJECTIVE: To improve communication between providers and LEP families on morning rounds in the Pediatric Inpatient Unit of Boston Medical Center. The aim for the QI initiative was to increase the percentage of rounding episodes with LEP patients/families in which the care plan was discussed between providers and families through the use of an in-person interpreter during morning rounds by 50% by February 28, 2015. METHODS: A quality improvement initiative utilizing residents, medical students, the unit coordinator and the ward assistant to introduce, streamline and standardize a process to incorporate interpreters on all morning rounds as needed for LEP families. The Model for Improvement was used for testing this initiative. Four Plan-Do-Study-Act (PDSA) cycles of testing were conducted between October 21, 2014 and February 20, 2015. The primary outcome was the proportion of rounding episodes for LEP patients/families in which the care plan was discussed between the provider and patients/families through an in-person interpreter. This data was collected through a newly created "Interpreter Rounding Form" (IRF) that served as a checklist for the process. The secondary outcome looked at patient satisfaction for both LEP and English proficient (EP) patients. This data was collected through survey questions from the CAHPS and AHRQ patient surveys. Process measures included if interpreter was requested, if interpreter was used and if any change in care management due to having in-person interpreter present. Balancing measures included duration of rounds, interpreter arrival time, and resident satisfaction. Language being included in resident verbal signouts and written signouts between teams was also tracked. Run charts were analyzed for all outcomes and measures to determine the effectiveness of changes tested. RESULTS AND CONCLUSIONS: For the first three PDSAs, there was a significant amount of variation in data measurement, which required focused efforts on better operationalizing our measurement framework. Changes were made after each PDSA to streamline the process and enforce completion of IRF, with which data was collected. For the fourth PDSA, starting in January 2015, completion rates for the IRF slowly increased to a median of 40%. Primary outcome data for PDSA 1-4 showed a median of 52% based on the rounding episodes that were recorded on the IRF forms, which suggests that the aim for a 50% increase in using an in-person interpreter on all morning rounds was achieved by February 28, 2015. However, this data may not reflect all the requests and encounters in which an in-person interpreter was used due to the missing data from a low completion rate of forms before PDSA 4. Further analysis of PDSA 4 data showed that though an in-person interpreter was used at a median of 38% of all encounters with LEP patients/families, providers were communicating with patients/families in their preferred language at 100% of the time; if did not request interpreter, providers used a resident or medical student who spoke the family's language 43% of the time. Patient survey data suggested that out of all patients in the unit, 80% of patients/families reported having "Always" understood the doctors, with LEP patients/families at a slightly higher percent than EP patients (100% vs 88%). Patients reported "Good" or higher for the quality of the information that was provided by the doctors on morning rounds at a median of 84%, with LEP patients at 100% compared to 84% for English-speaking patients. Qualitative analysis of patient responses showed that LEP patients liked the explanations and information provided in the morning rounds while EP patients mostly liked the attitude and approach of the doctors. One major limitation to our process was the constantly rotating residents/medical students and the need to train new teams. The project is ongoing with a focus on further standardization until a goal of 90% completion rate for IRF and 80% for primary outcome can be reached. Future PDSAs will encourage using medical interpreters for all LEP patient encounters and family-centered rounding.