Sunday
February 12, 2006
 |
| Cynthia Hedges Greising |
The emergency department at Sherman Hospital in Elgin, Ill., like other EDs around the country, treats many patients who have difficulty speaking and understanding English. Before the hospital had a staff of professional medical interpreters, Frank Pangallo, M.D., medical director of Sherman's ED, was concerned. "I used to walk out of rooms knowing that I didn't know everything," he said.
Because good communication is key to high-quality health care, Sherman and other hospitals and health systems nationwide are creating new initiatives to improve communication and outreach to patients, extending their efforts beyond the patient-doctor encounter. Many are targeting vulnerable patient populations, who face the greatest risk for miscommunication, by facilitating interpreter and other language assistance programs, addressing health literacy, strengthening workforce training, integrating technology and increasing patient involvement.
In 2005, the Ethical Force Program, led by the American Medical Association's Institute for Ethics, and the Health Research & Educational Trust (HRET), recognized eight hospitals for using innovative practices to provide patient-centered communication. These hospitals are Caritas Good Samaritan Medical Center in Brockton, Mass.; Harborview Medical Center in Seattle; the Iowa Health System; San Francisco General Hospital; Sherman Hospital in Elgin, Ill.; University of Virginia Health System in Charlottesville; WakeMed Health and Hospitals in Raleigh, N.C.; and Woodhull Medical and Mental Health Center in Brooklyn, N.Y.
In the last few months, researchers have been visiting these hospitals to gain insights for other hospitals and health systems that are also working to improve communication and outreach to patients in their communities.
For many hospitals, the impetus to change how their workforce communicates with patients is a commitment--or mission--to serve the community. Many hospitals established interpreter and language assistance programs because of changing patient demographics. Sherman Hospital serves a community that is about 25 percent Hispanic and, according to U.S. Census data, 30 percent of the people speak English less than "very well." Hospital staff described a "community need" for improved communication that "would make patients feel comfortable."
Communication gaps can lead to inefficient care, poor adherence to therapy and medical errors. As a result, many hospitals cited liability and legal issues as factors that influenced efforts to improve communication. Competition can also be an impetus. Caritas Good Samaritan Medical Center was competing with another local hospital for the same patients and realized it needed to respond--or patients would go elsewhere.
The first steps in establishing new programs include collecting data to assess patient and staff needs and setting up committees and focus groups. Woodhull Medical and Health Center conducted a comprehensive needs assessment including a community assessment, a staff survey and a review of patient and staff complaints about the lack of language assistance. Other hospitals' needs assessments have been less formal.
A "secret shopper" project at WakeMed Hospital had a huge impact on the evolution of their communication programs, according to staff. The secret shoppers were three women--white, non-English-speaking Hispanic and African American--hired to portray patients. Each shopper received an identical, detailed script and guidance on how to approach the system. The women posed as patients without insurance and visited the same five areas in the hospital. Their experiences showed that non-English-speaking patients were being treated as if they were invisible or deaf. As a result, WakeMed overhauled its hospital interpreter services to better meet the needs of all patients.
Once first steps were taken, hospitals began to establish new programs and policies, including ongoing efforts to train the workforce, monitor progress and spread successful programs systemwide.
Hospitals found that cross-system collaboration is crucial to instituting organizational change. Such collaboration requires senior leaders who get organizationwide buy-in as well as "champions" in middle management who create and implement the initiatives. Every hospital identified at least one middle manager--often the head of interpreter services, community outreach or patient relations--whose commitment, hard work and (always) passion were critical in establishing new programs.
Almost every hospital visited by researchers has established professional interpretation departments. Each hospital found that practitioners and patients, even those who are skeptical at first, rapidly become comfortable using trained interpreters and learn they can trust the quality of communication. Many hospitals rewrote policies so that neither untrained bilingual staff nor family members under age 18 are permitted to interpret. Such changes often create a culture shift. "We have now created a culture here that we know it is considered unacceptable for a patient to be floating out there by themselves--not being able to communicate, no one making an effort to communicate with them in their own language. It is safety, but it's also respect," said Candis Best, Ph.D., CEO of Woodhull Medical and Mental Health Center.
Most hospitals have access to telephone interpreters for times when on-staff interpreters are unavailable or when patients speak a language that none of the on-staff interpreters understand. San Francisco General is testing video medical interpretation (VMI): An interpreter appears live on a video screen for interpreting, and the equipment can be moved from room to room as needed.
Many interpreters serve as culture brokers, helping patients navigate the complex health care system and helping practitioners better understand patients' cultural backgrounds. At Caritas Good Samaritan, interpreters are part of the Community Outreach and Interpreter Services department (COIS) and work with local neighborhoods.
In addition to translating consent forms and other documents for patients who speak different languages, many hospitals needed to revise these documents for better understanding by all patients. Health literacy teams at Iowa Health System hospitals determined that their surgical consent form was written at a 16th-grade reading level.
Several hospitals emphasized that looking at informed consent as a process, and not a form, was essential, and that implementing small projects can make a difference. Patients at the University of Virginia Health System receive a phone call the day before surgery to make sure they understand the procedure they are about to undergo. One Iowa Health System hospital provides patients with paper and pencil during transport to write down questions. In addition, nurses and physicians learn how to recognize signs of literacy problems--such as sections of a form that have been left blank.
During visits to these hospitals, the research team always asked, "What are you doing that every hospital should be doing?" Here are some of the most common answers:
Integrate initiatives throughout the organization. Woodhull purposefully embedded its new initiatives, including language assistance, customer service and workforce training, into existing departments and initiatives. Though embedding one initiative in another can make it more difficult to assess the impact of the new initiative, it facilitates introduction and makes it easier to spread successful efforts throughout the organization.
Recruit diverse staff. San Francisco General Hospital believes a hospital's staff should reflect the communities it serves, and language skills are often a job qualification. Communities change over time, so hospitals need to keep rechecking demographics. Every community hospital can look up the census demographics of the neighborhoods it serves--for free.
Plan for training. Most hospitals provide many opportunities for training their workforce. New employees receive information on programs in their orientation sessions. New medical residents may receive cultural competency training. Ongoing training of current staff is also important in promoting new initiatives. The University of Virginia, among others, has trained staff to use the "teach back" or "repeat back" method to ensure that patients understand their preoperative instructions. "Training doesn't have to be exhaustive. Training cannot be one-shot; training has to be ongoing. The message needs to be in your system, in your policies and in how you are providing care to your patients," according to Yvette Villanueva of the human resources department at Woodhull.
Partner with other hospitals or community institutions. Several hospitals have partnered with local community colleges to train medical interpreters, thus increasing the pool of qualified applicants. WakeMed is working with Wake Technical Community College to develop an associate degree program for medical interpreters. To strengthen its health literacy program, Iowa Health System collaborates with the New Readers of Iowa and uses community volunteers to review patient documents and give feedback.
Recognize that work is ongoing. Communication initiatives do not have a definite beginning or end as do other quality initiatives. Staff at Iowa Health System emphasized that health literacy projects in particular take time to implement, but once the projects get going, they energize staff and encourage creativity.
No hospital can appreciate the benefits of providing patient-centered communication and care more than Caritas Good Samaritan Medical Center. In 2000, a large physician group switched its affiliation from Caritas Good Samaritan to another local hospital. This development hurt Good Samaritan financially, and its closure appeared imminent. Still, the hospital allowed its interpreters to continue accompanying patients to physician visits, even when those physicians started using the competitor hospital. But the patients were attached to the interpreters at Good Samaritan and remained loyal to the hospital. Patients picketed and lobbied on the hospital's behalf at the Massachusetts state house and prevented the hospital from closing. Today, Caritas Good Samaritan continues to offer outreach and communication services to a highly diverse patient community, but with a renewed sense of gratitude for these patients' fierce loyalty.
Cynthia Hedges Greising is a staff writer at the Health Research & Educational Trust in Chicago. Field research from the Institute for Ethics, American Medical Association, was used in this article.
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