Development and Field Test of Teamstepps Health Communications Tools to Improve Safety for Patients with Limited English Proficiency

Theoretical Background and research questions/hypothesis:  Approximately 24 million people (8.5% of the U.S. population) have limited English proficiency (LEP). Research suggests that LEP patients are more frequently subject to clinically significant communication errors in U.S. hospitals compared to English-speaking patients, resulting in greater likelihood of serious harm from medical errors. To address this challenge, the Agency for Healthcare Research and Quality (AHRQ) has developed a new evidence-based TeamSTEPPS training module and Hospital Guide to improve medical team communications with the goal of enhancing LEP patient safety.  This is the first TeamSTEPPS patient safety module designed to meet the safety needs of a specific patient population through tailored communication tools.  The purpose of this study was to field-test the TeamSTEPPS module intervention and assess its feasibility and effectiveness in hospital settings.

Methods:  A mixed-methods approach (literature review, qualitative and quantitative research) was used to develop the evidence-based TeamSTEPPS module which included videos, a slide presentation, structured communication tools, exercises and an evaluation guide.  A case study design was then used to pilot-test the module. A training of trainers was held with two master-trainers from each of three hospitals, and each master-trainer team customized, delivered and evaluated the intervention in their hospital setting.  Qualitative interviews were conducted with Master-trainers and change teams over a 3-month period, followed by a site visit, to learn about their experiences, observe local adaptations, and identify technical assistance needs. Evidence was triangulated from multiple data sources including interviews, observation and document review.

Results:  The intervention was successfully implemented in each hospital despite barriers including hospital leadership concerns about cost, competing quality initiatives and limited interpreter resources.  Each site trained approximately 100 staff members including clinicians, nurses, technicians and interpreters.  Units involved included labor and delivery, the emergency department (ED) and pediatric primary care clinics.  Hospitals also implemented structural changes such as the addition of full-time interpreter staff and the clarification of hospital policies on interpreter use. Hospital staff only partly used the evaluation guide and metrics provided; some attempted to use alternate metrics and methods, but evaluation remained a challenge. Nonetheless, in our site visits and interviews, clinical staff reported greater awareness of the need to call interpreters instead of getting by with gestures and providers’ limited knowledge of patient language.  Providers also reported including interpreters in briefs with the care team, and interpreters reported feeling more empowered to raise and address patient communication issues with providers following the training. 

Conclusions:  Despite numerous implementation challenges, pilot-test results suggest that the TeamSTEPPS LEP module and communication tools are simple and flexible enough to be implemented in a variety of settings. The intervention can also serve as a catalyst for system change to improve medical communications, such as the addition or efficient re-allocation of interpreter resources.

Implications for research and/or practice:  The TeamSTEPPS LEP module is a feasible intervention to improve safety for LEP patients.  It may also facilitate the implementation of the new Joint Commission standards on Patient-Centered Communication.  Further research is needed on larger-scale dissemination and implementation.