AAMC Reporter: July 2007

Found in Translation: Hospitals Improve Quality Through Language Services

—By Stephen Pelletier, special to the Reporter

Census figures tell us that, at home, nearly 20 percent of United States residents speak a language other than English. Within this group, nearly 45 percent speak English "less than 'very well.'" Demographics like those can impact communication, but in hospitals, they can be even more problematic; research shows that patients with limited English tend to get less attention and poorer care.

To serve growing numbers of patients with limited English proficiency, or LEP, hospitals have been rapidly adding capacity for medical interpretation. But therein lies a dilemma. The practice of language services in health care lacks uniform standards and widely accepted systems for measuring quality. Specifically, for example, the field needs more sophisticated and standardized means for assessing the needs of LEP patients, the quality of their care, provider performance, and costs.

To help address these issues, the Robert Wood Johnson Foundation has funded a project designed to strengthen the language services infrastructure. Ten health care facilities, including several academic medical centers, were chosen to participate in "Speaking Together: National Language Services Network," based at the George Washington University (GWU) School of Public Health and Health Services. The goal is to standardize some of the ways in which practitioners collect and analyze basic data about hospital interpreter services—information that can be used to assess programs, help shape necessary changes, and ultimately improve the quality of health care for patients with LEP.

"There isn't necessarily a consensus about the best way to provide language services," said the project's director, Marsha Regenstein, Ph.D., an associate research professor at GWU. Moreover, she observed, good data are hard to find. Hospitals have some relevant statistics on language services, but do not always collect data "in a uniform way" and in forms that can be "productive for quality improvement." To change that, Regenstein said, "Speaking Together" is working to "apply some rigor to data collection that is uniform across a set of hospitals."

The project's most important contribution comes in the form of five new measures to improve quality of language services. The first two measures gauge how effectively hospitals screen patients for their preferred spoken language and how well they complete intake assessments and discharge instructions for LEP patients. The other three quantify patient wait time, interpreter wait time, and overall time spent interpreting. The 10 hospitals are pilot-testing the measures.

As tools for improvement, the five measures are based on the six "domains of quality"—safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness—developed by the Institute of Medicine. They also follow a recent Joint Commission recommendation that hospitals use well-trained medical interpreters.

Halfway through its 16-month lifespan, "Speaking Together" is just starting to yield results. Overall, participating hospitals are making more productive links among data collection, language services, and quality improvement. Regenstein said that project participants are beginning to clarify better ways to identify true demand for language services and to improve strategies for tracking the delivery and costs of interpreter services. More work needs to be done, however, before the findings can be shared as models.

In the field, though, "Speaking Together" is already having a direct impact on its participating hospitals. One such hospital is the Cambridge Health Alliance (CHA), an academic public health system in Boston's northern suburbs. More than half its patients speak a primary language other than English. CHA practitioners encounter more than 100 languages annually, and communicate regularly in more than 30 languages.

Through "Speaking Together," CHA is "looking very closely at the accuracy and timeliness" of its language services and at patient satisfaction, said Helena Santos-Martins, M.D., medical director of CHA's East Cambridge Health Center.

"We have had to change the way we collect data," Santos-Martins said.

In July, for example, CHA started testing new "hard stops" integrated into electronic patient records that require providers to chart key questions about language services.

At the University of Michigan Health System, only 6,000 of the 500,000 outpatients who visit annually have LEP. But as Connie Standiford, M.D., associate medical director of ambulatory care services, observed, the fact that the Michigan system serves a diverse community that speaks more than 40 languages requires a robust infrastructure. In just the last decade, demand for interpretation has pushed Michigan to expand its language services staff from two part timers to 22 full-timers, supported by a pool of more than 100 contractors.

Applying "Speaking Together"'s five measures led Michigan to change the way it asks patients about language preferences. They also increased their overall capture of information about language from 40 percent to 70 percent. "We have made it more ingrained in our system as we register patients and conduct follow-up visits," Standiford said. In addition, to improve efficiencies in serving the system's 16 far-flung sites, Michigan has been experimenting with interpretation via telephone rather than in person.

Meanwhile, the University of California, Davis Health System has been using dedicated interpreters, rather than standard medical assistants, to help speakers of Spanish, Russian, and Hmong—the three languages they hear the most—complete routine depression screenings. The interpreters are then assigned to the same patients "to provide some continuity of care," said Sergio Aguilar-Gaxiola, M.D., Ph.D., a UC Davis internal medicine professor. Researchers intend to measure whether this approach improves how well patients adhere to instructions from physicians and come back for follow-up visits.

"We have known for a while that medical interpreters do much more than just interpretation," Aguilar-Gaxiola said. "They also contribute significantly to the quality of care. This is one of the first studies in the country that is deliberately trying to associate language services with indicators of quality of care."

Related Resource

AAMC Guidelines for Use of Medical Interpreter Services

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