1. 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 Tools for Identifying and Preventing Medical Errors in Patients with Limited-English Proficiency

2. Outline  LEP Patients and Patient Safety  Project Overview and Key Components  Methodology & Select Data Sources  Findings and Key Themes  Recommendations: Hospital Guide & TeamSTEPPS

3. 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

4. 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 TeamSTEPPS 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 the Disparities Solutions Center at MGH in collaboration with Abt Associates, Inc., Cambridge

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

6. Advisory Board Key Informant Interviews Preliminary Hospital Guide Methodology and Data Sources Interviews Frontline Staff Environmental Scan Field Testing Preliminary Team STEPPS Final Hospital Guide Final Team STEPPS IMPLEMENTATIONIMPLEMENTATION Adverse Events Database Interpreter Pilot Results Identify Role of Language Barriers in Pt Safety Events Document how Hospitals are Addressing LEP Errors Background Preliminary Tool Development Testing and Validation Final Product Development Dissemination and Adoption Town Meeting

7. 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* Analysis of adverse event reporting databases of two hospitals in the Boston-area for the years 2006 to 2008 supplemented by the interpreter services databases for the same years. Combined database contained all adverse events in the hospital that were compiled by the patient safety and quality improvement staff at the study hospitals

8. 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 of 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

9. 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

10. 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

11. 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

13. Hospital Guide  Educate leaders with the background and evidence on medical errors that occur due to language barriers  Present a set of strategies and training tools to create systems and an organizational culture to better identify, prevent, report, and address medical errors that occur due to language barriers in a variety of hospital settings  Provide a set of practical case examples that solidify learning  Provide resources which can be useful in developing a robust LEP patient error reporting and response system

14. TeamSTEPPS Training Module  Teamwork system to improve patient safety –Rooted in 20 years of research on teamwork –Helps persons of lower hierarchical status communicate about patient safety risks –Teaches persons of higher hierarchical status to better respond  Video vignette with LEP patient safety scenarios and training manual  TeamSTEPPS structured communication skills to facilitate communication between the medical team, bilingual frontline staff, and LEP and diverse patients

15. Summary  There is a growing body of evidence that has identified the link between LEP and medical errors  Hospitals can play a major role in addressing errors by building safety systems with attention to LEP issues  Hospital Guide and TeamSTEPPS will provide guidance and practical tools to lead the field

16. Adverse Events Database  Analysis of adverse event reporting databases of two hospitals in the Boston-area for the years 2006 to 2008  Data were supplemented by the interpreter services databases for the same years  Combined database contained all adverse events in the hospital that were compiled by the patient safety and quality improvement staff at the study hospitals  For each adverse event, the combined database contained information on the patient’s age, whether patient had ever used an interpreter, date of admission, location and time of the adverse event, type of adverse event, whether an injury occurred, and severity of the injury

17. MGH Interpreter Pilot Project  Aim: to gather information about the types of situations or incidents that negatively impact: –The safety of patients with limited English Proficiency (LEP) –The experience of care by racial and ethnic minority patients  Areas of Guidance –Patient’s Safety at Risk, Unprofessionalism, Lack of Training –AHRQ Format: Incident, Near-Miss, Unsafe condition  Interpreters reported events by: –Template Form –Audio Recordings with Direct Supervisor  Incentive: –Monthly Lottery: $50 MGH Gift Card General Store/Coffee Central  Timeline: –Data Collection: April 2009-March 2010

18. Town Hall Meeting  1 hr 15 min phone meeting with 19 participants (6 hospitals, 1 health plan, and 3 hospital associations represented)  Purpose – identify best practices for preventing, reporting, and documenting medical errors for LEP  Discussion Focused on Three Areas: –Methods for collecting and reporting medical errors –Mechanisms for monitoring medical errors –Strategies for preventing/addressing medical errors  Qualitative analysis: coding of key themes

19. Key Informant Interviews  18 in-depth interviews (9 frontline and 9 leaders) conducted via phone or in-person in 3 Boston hospitals  Frontline staff: (received $50 cash incentive) –Knowledge and understanding of pt safety and medical errors  Interpreters (3)  Nurses (3)  Other bilingual receptionists (3)  Leaders: –Perspectives on identification, reporting, and preventing medical errors  Interpreter Services (3)  Nurse Managers (3)  Patient Safety Leaders (3)  Qualitative analysis - coding of key themes