Welcome to the Disparities Solutions Center s Web Seminar Series Identifying and Preventing Medical Errors in Patients with Limited-English Proficiency: New Tools for the Field Tuesday, October16, 2012 1:00PM 2:30PM ET This web seminar will start momentarily Identifying and Preventing Medical Errors in Patients with Limited-English Proficiency: New Tools for the Field Presenters Joseph Betancourt, MD, MPH Director, The Disparities Solutions Center at Massachusetts General Hospital Cindy Brach, MPP Senior Health Policy Researcher, Agency for Healthcare Research and Quality Anabela Nunes, MBA Director of Medical Interpreter Services, Massachusetts General Hospital John Cowden, MD, MPH Interim Section Chief General Pediatrics, Medical Director Office of Equity and Diversity Children's Mercy Hospitals and Clinics 1
The Hospital Guide and LEP Module Available at: http://www.ahrq.gov/teamsteppstool s/lep/index.html Cindy Brach, MPP Cindy Brach, MPP, is a Senior Health Policy Researcher at the Agency for Healthcare Research and Quality (AHRQ). She conducts and oversees research on health literacy, cultural and linguistic competence, system design innovations, and Medicaid and SCHIP. Cindy leads AHRQ s health literacy and cultural competence activities, such as the development of the a module for improving care to patients with limited English proficiency and adapting tools to improve the hospital discharge process for diverse patients. She serves on the Institute of Medicine Roundtable on Health lthliteracy and was a member of the National Nti Project Advisory Committee for updating the National Standards for Cultural and Linguistic Competence. Her publications include Integrating Literacy, Culture, and Language to Improve Quality of Health Care for Diverse Populations and Crossing the Language Chasm, and she was the editor of Setting the Agenda for Research on Cultural Competence in Health Care. 2
Anabela Nunes, MBA Anabela Nunes, MBA, is the director of Medical InterpreterServices at the Massachusetts General Hospital (MGH), Boston, Massachusetts. She oversees a complex operation which integrates the delivery of language services in a variety of modalities, face to face, telephonic and video using state of the art scheduling system that facilitates the efficient allocation of resources across a large sprawling urban campus. She leads a group of 36 staff medical interpreters and 50 freelance interpreters who provide interpreting services in over 30 languages. During her tenure, Ms. Nunes has been part of a number of initiatives to enhance accessibility to and increase utilization of professional medical interpreters through the creation and deployment of I POPs (Interpreter Phone on Pole) and more recently V POPs (video medical interpreting). John Cowden, MD, MPH John Cowden, MD, MPH, is Interim Section Chief of General Pediatrics at Children's Mercy Hospitals and Clinics. He also serves as Medical Director of Children's Mercy's Office of Equity and Diversity, which guides the organization's efforts toward cultural competency and health equity. He is founder and co director of CHICOS and Enlaces, a Spanish language resident care clinic and a medical resident Spanish class, respectively. Dr. Cowden s research interests include provider patient communication, provider bias, and access to health care for minorities, specifically thosewho do notspeak English. In his bilingual clinical practice, he serves Spanish speaking families throughout the Kansas City metropolitan area. He teaches medical students from the University of Kansas City Missouri and pediatric residents at the Children s Mercy Hospitals and Clinics. 3
Tools for Identifying and Preventing Medical Errors in Patients with Limited-English Proficiency Joseph R. Betancourt, M.D., M.P.H. Director, The Disparities Solutions Center Senior Scientist, Mongan Institute for Health Policy Director for Multicultural Education, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School Quality Health Care Health care should be Safe Effective Patient-centered Timely Efficient Equitable 4
Background: Disparities, LEP and Patient Safety Approximately 24 million (8.5% of the U.S. population) are defined as having Limited English Proficiency (LEP) Adverse events affect LEP patients more frequently and severely than they affect English speaking patients LEP patients more likely to experience medical errors due to communication problems than English speaking LEP patients more likely to suffer from physical harm when errors occur Project Overview Goal: Develop, test, and implement two new tools to reduce patient harm due to language barriers and cross-cultural care communication problems Hospital Guide on preventing, identifying, and reporting medical errors due to language barriers and cross-cultural communication problems A new training module, focused on team behaviors to improve safety in LEP and culturally diverse patient populations Funded by the Agency for HealthCare Research and Quality (AHRQ) and conducted by Abt Associates, Inc. and the Disparities Solutions Center at Massachusetts General Hospital 5
Research and Development Team Disparities Solutions Center Megan Renfrew, MPH Aswita Tan-McGrory, MPH, MBA Lenny Lopez, MD, MPH, Mdiv Alexander R. Green, MD, MPH ABT Associates Melanie Wasserman, PhD Mark Spranca, PhD AHRQ Cindy Brach, MPP Methodology and Data Sources Environmental Scan Adverse Events Database Interpreter Pilot Results Interviews Frontline Staff Key Informant Interviews Town Meeting Preliminary Hospital Guide Preliminary Team STEPPS Preliminary Tool Development Advisory Board Field Testing Final Hospital Guide Final Team STEPPS Final Product Development I M P L E M E N T A T I O N Background Identify Role of Language Barriers in Pt Safety Events Document how Hospitals are Addressing LEP Errors Testing and Validation Dissemination and Adoption 6
Adverse Events Database From 2006-8, 840 events in LEP patients (of 16,708 total) LEP patients more likely to have adverse events attributable to medication errors (57% vs 50%) and procedure consent errors (.12% vs.07%) compared to English speaking patients* ercent pe Adverse Events Attributable to Medication Errors in English Speaking and LEP Patients 58% 56% 54% 52% 50% 48% 46% English speaking Limited English proficiency rcent per Adverse Events Attributable to Procedure Consent Errors in English Speaking and LEP Patients 0.15% 0.10% 0.05% 0.00% English speaking Limited English proficiency Betancourt JR, Renfrew MR, Green AR, et al. Improving patient safety systems for patients with limited English proficiency: a guide for hospitals. (Prepared by the Disparities Solutions Center, Mongan Institute for Health Policy at Massachusetts General Hospital and Abt Associates, Cambridge, MA, under Contract No. HHSA290200600011I). Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ Publication No. 12-0041. September 2012. MGH Interpreter Pilot Project Overview of Key Themes Misuse of interpreter services No interpreter present, use of family members, providers using poor language skills) Miscommunication between patients and providers Poor communication skills, not listening to patients complaints, lack communication between patient and broader care team Cultural issues Inappropriate questions posed to patients (e.g. religion); Providers lack of understanding Professionalism Rudeness to interpreters and not respecting or understanding their role Informed Consent Consent signed without interpreter present 7
Broad Key Themes Interviews & Town Hall Meeting: Current Hospital Strategies/Efforts to Address Linguistic and Cultural Sources of Error Language data collection not systematic or routine across hospitals Safety reporting systems often do not include fields to identify language or interpreter as playing a role precludes stratification of errors and impedes root cause analyses Hospitals do not routinely monitor medical errors for LEP and rarely generate reports for high risk scenarios Challenges with data collection (merging of databases not designed for this purpose) Broad Key Themes Interviews & Town Hall Meeting: Common Causes of Medical Errors for LEP Use of non-qualified interpreters Use of family members/friends or house staff Provider use of basic language skills to get by Cultural beliefs/values impacting patient care 8
Broad Key Themes Interviews & Town Hall Meeting: High Risk Scenarios Medication Reconciliation Informed Consent Processes Patient Discharge Emergency Department Visits Pre, Peri and Post-Operative Care Hospital Guide Educate leaders with background and evidence on medical errors that occur due to LEP Present strategies and training tools to create systems and an organizational culture to better identify, report and prevent medical errors that occur due to LEP in a variety of hospital settings Provide a set of practical case examples that solidify learning Provide resources which can be useful in developing an LEP patient error reporting and response system 9
The LEP Module Cindy Brach, AHRQ 10
Health Care and Teamwork Communication failures account for the overwhelming majority of adverse events Medical care is complex and human performance has inherent limitations Effective teamwork can prevent mistakes Embedding evidence-based training and team behaviors can enhance safety Team training has a positive impact on work force retention Mod 1 05.2 Page 21 AHRQ/DoD Partnership Activities began in 2002 Expert Panel Comprehensive literature review and case study analysis Clinical measures of teamwork Medical Team Training Curriculum Edited Handbook National Implementation Principles and Guidelines Tools for Training and Measurement Evidence- Based Methods Mod 1 05.2 Page 22 11
National Implementation Project Created a national infrastructure to support the adoption of Quality Improvement Organizations Hospital Engagement Networks ACTION Partners Academic Medical Centers Other Countries (Japan, Australia, Netherlands) Spread : trained over 5000 Master Trainers who trained 25,000 trainees to date Mod 1 05.2 Page 23 Products and Materials Core Rapid Response Systems (RRS) Module Limited English Proficiency (LEP) Module Long-term Care Primary Care Mod 1 05.2 Page 24 12
Benefits of including interpreter on the care team Receive more complete and accurate information Facilitate better clinical decisions Receive support from a cultural broker who is also an advocate for the patient Meet the new Joint Commission patient-centered communication standards (in effect July 1, 2012) Mod 1 05.2 Page 25 How the LEP module can help 1.5 hour staff training module so unit staff and interpreters can: Understand the risks to LEP patients If LEP call a professional medical interpreter Identify and raise patient communication issues 4-hour train-the-trainer the trainer program: Hospitals train their own staff Mod 1 05.2 Page 26 13
Training Module Content Slide decks with videos and exercises Train-the-Trainer materials, including instructor guides, readiness assessment, and handouts Hospital Guide Evaluation Guide, with provider behavior and patient outcome surveys Mod 1 05.2 Page 27 Assemble the team CUS Two Challenge Rule Brief Psychological Safety Check-Back Teach Back Tools Mod 1 05.2 Page 28 14
Stop the Line: CUS (insert video clip of CUS here) Mod 1 05.2 Page 29 Field Test Module implemented in all 3 hospitals Settings: 3 hospitals in MO, DE and NC Labor and Delivery Emergency Department, OB/Gyn Pediatric primary care /non- hospital 268 staff members trained including doctors, nurses, interpreters, registration staff Mod 1 05.2 Page 30 15
Field Test Findings Focus for each hospital was different: Use of a qualified communicator Briefs with interpreters Phone interpreter use if no in-person interpreter Catalyst for institutional changes Reorganize/reallocate interpreters Clarify interpreter use policies Bilingual provider training/certification Mod 1 05.2 Page 31 Field Test Results Qualitative results: Clinical staff more aware of need to call interpreter Interpreters more empowered to raise and address communication issues with clinical team Quantitative results: Hospital 1: pre-test convinced leadership no post-test Hospital 2: High satisfaction, increase in knowledge, R/E/L data quality issues interpreter t use data unusable Hospital 3: High satisfaction, increase in knowledge scores, R/E/L data quality issues interpreter use data unusable Mod 1 05.2 Page 32 16
Conclusions Module can be implemented in a variety of settings /non- Hospital/ primary care clinic Catalyst for change R/E/L data Collection/use still a barrier to formal evaluation Mod 1 05.2 Page 33 More Information To access the TeamSTEPS Module for Limited English Proficiency, go to: http://www.ahrq.gov/teamsteppstools/lep/index.html For more information about, go to: http://teamstepps.ahrq.gov/ Mod 1 05.2 Page 34 17
Limiting Medical Errors among the Limited English Proficient Anabela Nunes Director MGH Medical Interpreter Services 90,000 MGH Interpretations Inpatient: 26% Total Number of Encounters 80,000 70,000 60,000 50,000 40,000 Inpatient: 28% Inpatient: 27% 75,792792 Inpatient: 28% 65,551 Inpatient: 25% 57,062 Inpatient: 23% 49,248 40,168 82,464 30,000 20,000 FY 06 FY 07 FY 08 FY 09 FY 10 FY11 18
Near misses Wrong language Anecdotally Incorrect or improper care Getting by LEP Safety Initiatives Quality and Safety Rounds Interpreter Services leadership included in Executive Quality and Safety Rounds Standard script for staff Identify safety concerns for LEP patients Successes In progress Tentative start date in the Fall 2012 Challenges Frequency of rounds Competing goals 19
LEP Safety Initiatives Interpreter Rounds Standard script Inform patients of right and access to interpreter services Assess how language needs are met Successes More rounds done than anticipated Valuable data gathering will help identify new initiatives Rounding on any language In progress Data collection and analysis for evaluation Challenges Standardize interpreter rounds Round on all patients Coordinate rounds with other disciplines LEP Safety Initiatives Interpreter Training Quality & Safety 101, including reporting Successes Increased awareness of their role in LEP patient safety Greater understanding of value of reporting Increased number of reports being submitted In progress Training and implementation on specific communication skills Challenges Empowering interpreters to speak up in the moment Recognition as a member of the medical team 20
Children's Mercy Hospitals & Clinics Kansas City, Missouri John D. Cowden, MD, MPH Enhancing Safety for Patients with Limited English Proficiency 21
Pediatric Care Center Yellow Clinic (1 of 4 colors) Spanish Language Focus Check-Back is LEP Mod 6.11.10 Page 44 22
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Question and Answer Period Please submit your questions online by typing them into the Question box on the right side of the screen and clicking the Send button. The panelists will try to answer the questions as succinctly as they can. Depending on the size of the audience, we may not be able to answer all questions. Identifying and Preventing Medical Errors in Patients with Limited-English Proficiency: New Tools for the Field Presenters Joseph Betancourt, MD, MPH Director, The Disparities Solutions Center at Massachusetts General Hospital Cindy Brach, MPP Senior Health Policy Researcher, Agency for Healthcare Research and Quality Anabela Nunes, MBA Director of Medical Interpreter Services, Massachusetts General Hospital John Cowden, MD, MPH Interim Section Chief General Pediatrics, Medical Director Office of Equity and Diversity Children's Mercy Hospitals and Clinics 25
The Hospital Guide and LEP Module Available at: http://www.ahrq.gov/teamsteppstool s/lep/index.html 26
Thank you for your participation! www.mghdisparitiessolutions.org 27