Addressing Language-barriers for Spanish-speaking Patients at a Women's Health Clinic

Hispanics living in Utah experience health disparities related to economic, sociocultural, environmental, and geographic disadvantages. Language barriers contribute to these disparities, resulting in disproportionate risks for illness, chronic disease, and poor maternal/infant outcomes. Professional medical interpretation and language-concordant written resources are evidence-based practices that address language barriers, promote patient satisfaction, and positively impact health outcomes. Spanish-speaking patients at Valley Women's Health, American Fork Division, experience language barriers, leading to unequal care compared to English-speaking patients. Inconsistent use of professional medical interpretation and inadequate provision of Spanish forms and handouts are noted as barriers. Staff and providers express dissatisfaction with language services, citing concerns such as video interpretation service functionality, limited time for extended visits on clinic schedules, and inadequate language-appropriate written resources. Culturally and Linguistically Appropriate Services (CLAS) are evidence-based standards that address these concerns while ensuring compliance with government and legal requirements. This Doctor of Nursing Practice scholarly project aimed to address a health inequity experienced by Spanish- speaking patients by improving clinic policies and practices related to language-appropriate services at a women's health clinic. The Model for Improvement guided this quality improvement (QI) initiative by providing a framework for team development and function, establishing objectives and measures, and monitoring intervention effectiveness through Plan-Do-Study-Act cycles. Data collection methods included chart reviews, pre-and post-implementation surveys, and weekly rounding. Qualitative and quantitative methods were used for data analysis and reporting the interventions' effectiveness, feasibility, and usability. Multiple interventions were developed to achieve the project's aims of increasing the use of professional language interpretation and Spanish written resources. Clinic policies were revised to correspond with government regulations, legal requirements, and CLAS standards. A clinic language services workflow was developed and disseminated with a training video that was produced for the project. All commonly used English forms and handouts were professionally translated into Spanish and a centralized computer file folder for Spanish resources was established. Interventions to promote documentation of interpretation in the electronic health record included adding flags to label charts for patients requiring interpretation and adding fields addressing interpretation use to commonly used note templates. Pre- and post-implementation data analysis revealed that bilingual provider visits increased by 45%, while professional language interpretation usage rose by 36%. The quantity of Spanish- language written resources increased by 244%. Weekly visits by Spanish-speaking patients increased from 7.3 to 7.9, representing an 8% increase. The staff and provider surveys reflected high levels of satisfaction with the project. In the post-implementation survey, 93.6% of respondents credited the project's interventions with improving services to Spanish-speaking patients. This QI project addressed a health inequity in a vulnerable population, showcasing the feasibility and usability of a practical implementation strategy for delivering evidence-based, language- appropriate services to Spanish-speaking patients. Revised clinical policies and streamlined workflows bolstered staff and provider satisfaction, leading to enhanced utilization of professional language interpretation, bilingual providers, and Spanish forms and handouts. The project findings will be shared with other clinic sites within this women's health organization across Utah.

1 Addressing Language Barriers for Spanish-Speaking Patients at a Women’s Health Clinic Erica C. Nelson, Benjamin Becker, Teresa Garrett College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III March 31, 2024 2 Abstract Background Hispanics living in Utah experience health disparities related to economic, sociocultural, environmental, and geographic disadvantages. Language barriers contribute to these disparities, resulting in disproportionate risks for illness, chronic disease, and poor maternal/infant outcomes. Professional medical interpretation and language-concordant written resources are evidence-based practices that address language barriers, promote patient satisfaction, and positively impact health outcomes. Local Problem Spanish-speaking patients at Valley Women’s Health, American Fork Division, experience language barriers, leading to unequal care compared to English-speaking patients. Inconsistent use of professional medical interpretation and inadequate provision of Spanish forms and handouts are noted as barriers. Staff and providers express dissatisfaction with language services, citing concerns such as video interpretation service functionality, limited time for extended visits on clinic schedules, and inadequate language-appropriate written resources. Culturally and Linguistically Appropriate Services (CLAS) are evidence-based standards that address these concerns while ensuring compliance with government and legal requirements. This Doctor of Nursing Practice scholarly project aimed to address a health inequity experienced by Spanishspeaking patients by improving clinic policies and practices related to language-appropriate services at a women’s health clinic. Methods The Model for Improvement guided this quality improvement (QI) initiative by providing a framework for team development and function, establishing objectives and measures, and 3 monitoring intervention effectiveness through Plan-Do-Study-Act cycles. Data collection methods included chart reviews, pre-and post-implementation surveys, and weekly rounding. Qualitative and quantitative methods were used for data analysis and reporting the interventions' effectiveness, feasibility, and usability. Interventions Multiple interventions were developed to achieve the project’s aims of increasing the use of professional language interpretation and Spanish written resources. Clinic policies were revised to correspond with government regulations, legal requirements, and CLAS standards. A clinic language services workflow was developed and disseminated with a training video that was produced for the project. All commonly used English forms and handouts were professionally translated into Spanish and a centralized computer file folder for Spanish resources was established. Interventions to promote documentation of interpretation in the electronic health record included adding flags to label charts for patients requiring interpretation and adding fields addressing interpretation use to commonly used note templates. Results Pre- and post-implementation data analysis revealed that bilingual provider visits increased by 45%, while professional language interpretation usage rose by 36%. The quantity of Spanishlanguage written resources increased by 244%. Weekly visits by Spanish-speaking patients increased from 7.3 to 7.9, representing an 8% increase. The staff and provider surveys reflected high levels of satisfaction with the project. In the post-implementation survey, 93.6% of respondents credited the project's interventions with improving services to Spanish-speaking patients. Conclusions 4 This QI project addressed a health inequity in a vulnerable population, showcasing the feasibility and usability of a practical implementation strategy for delivering evidence-based, languageappropriate services to Spanish-speaking patients. Revised clinical policies and streamlined workflows bolstered staff and provider satisfaction, leading to enhanced utilization of professional language interpretation, bilingual providers, and Spanish forms and handouts. The project findings will be shared with other clinic sites within this women’s health organization across Utah. Keywords: Culturally and Linguistically Appropriate Standards, health disparities, Hispanic women, Spanish-speaking patients, language-appropriate written resources, bilingual providers, professional language interpreters 5 Problem Description Effective communication between patients and their healthcare providers is essential. Patients with limited English proficiency face difficulties accessing high-quality healthcare and tend to experience worse health outcomes within the United States healthcare system, where English is the predominant language (Diamond et al., 2019). Linguistically appropriate care aims to promote effective communication, quality care access, and improved patient outcomes (Think Cultural Health, n.d.). The Hispanic population in Utah increased by 36% between 2010 and 2020, according to the Utah Department of Health and Human Services (Office of Health Equity, 2023), and is expected to rise by another 39% by 2030 (Kem C. Gardner Policy Institute, n.d.). Hispanics comprise the largest non-White ethnic group in Utah County, at 13.1% of the population (Office of Health Equity, 2022). Hispanics living in Utah experience health disparities related to economic, sociocultural, environmental, and geographic disadvantages (Office of Health Equity, 2022). These disparities include a lack of health insurance, a lack of primary care provider, inadequate routine medical and dental care, and inadequate first-trimester prenatal care (Office of Health Equity, 2022). Language barriers can contribute to disparities for minority groups, resulting in disproportionate risks for illness, chronic disease, and poor maternal/infant outcomes (Rayment-Jones et al., 2021; Timmins, 2002). Title VI of the Civil Rights Act of 1964 prohibits discrimination against patients with limited English proficiency and ensures they receive equal access to programs and opportunities that are federally funded. Section 1557 of the Affordable Care Act (Patient Protection and Affordable Care Act, 2010) ensures that high-quality interpretation via certified medical interpreters is offered to those with limited English proficiency in healthcare settings. Violations 6 of Section 1557 are investigated by the Office for Civil Rights (U.S. Department of Health and Human Services, 2017) and can result in legal action. At a Utah women’s health clinic in American Fork, staff and providers care for patients who speak multiple languages. Interpretation services are often needed because few staff are bilingual. Visits where interpretation services are used can take up to twice the scheduled time. Providers report that video interpretation services often do not work correctly causing additional delays and frustration for providers and patients. Because of these problems, interpretation services are used inconsistently and substituted by inappropriate forms of interpretation via patients’ family members or clinic staff who are not certified as medical interpreters. It has also been reported that language-appropriate written resources for patients are unavailable or have been mistranslated by lay translators. Staff complain that Spanish forms do not match their English counterparts, so non-Spanish-speaking staff do not know how to use them. In the absence of forms in Spanish, essential documents like consent forms are sometimes read line by line via interpretation, which is a tedious and time-intensive process. Appropriate documentation of the provision of language services is lacking. Patients’ preferred language is sometimes not documented appropriately, and there is no consistent way to document if they refuse medical interpretation. The use of professional interpretation with a correlating reference number should be documented with each encounter; instead, it is recorded intermittently and in different locations in the patient’s chart. A review of clinic policies related to language services found they were incomplete and solely focused on appropriately using the interpretation system via iPads. The clinic policies are not used during routine or new-employment training for staff and providers. Protocols and 7 workflows that review task management and responsibilities have yet to be created to address language barriers. Available Knowledge The national standards for Culturally and Linguistically Appropriate Services (CLAS) were developed by the United States Health and Human Services Office of Minority Health in 2000 and enhanced in 2013 (Think Cultural Health, n.d.). These standards fulfill the requirements of Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act (Patient Protection and Affordable Care Act, 2010). The recommendations comprise evidence-based interventions that address health disparities, improve health equity, and promote healthcare quality (Think Cultural Health, n.d.). The section on communication and language assistance (Figure 1) ensures that language assistance is offered to those with limited English proficiency, recommends that language interpreters are certified and competent, and encourages language-appropriate written resources (Think Cultural Health, n.d.). Language-concordant care occurs when a bilingual healthcare provider communicates effectively in the patient’s own language. It is the primary preferred communication method by patients with limited English proficiency and is associated with positive outcomes (Diamond et al., 2019). When a language-concordant provider is unavailable, the standard of care is to use a professional language interpreter. This can be done in person or via a video application for remote interpretation. Language interpreter use is associated with positive outcomes, such as healthcare utilization, satisfaction, communication, and clinical outcomes (Karliner et al., 2007). Patients who prefer to speak languages other than English also prefer written materials in their language of choice that use plain language and graphics (De Alba Rosales et al., 2020; Jang et al., 2018). 8 The effects of limited English proficiency on Hispanic women’s health and maternal outcomes have not been well-studied. Immigrant status and race are not often differentiated from preferred language in outcomes data, further complicating current knowledge of the issue (Togioka et al., 2022). Limited evidence indicates that women who prefer to communicate in languages other than English experience disparities in women’s health care. Examples include decreased preventative screenings (Ali & Watson, 2018), limited obstetric care, and poor outcomes like increased rates of cesarean section, postpartum depression, and breastfeeding difficulties (Comfort et al., 2023; Togioka et al., 2022). While rates of cesarean section are particularly high for Spanish-speaking women, interpreter use has a mitigating effect (Comfort et al., 2023). Quality improvement (QI) projects designed to promote interpreter use are effective and feasible (Behairy et al., 2023; Rahbhandari et al., 2021). However, there is a notable gap in the existing literature concerning effective QI initiatives to facilitate linguistically-appropriate healthcare services for women, particularly Spanish speakers. Rationale The scientific evidence and government directives in favor of these interventions are strong (Patient Protection and Affordable Care Act, 2010; Civil Rights Act, 1964; Diamond et al., 2019); however, they are not used consistently in healthcare settings (Isbey et al., 2022; Schwei et al., 2018). QI projects have been shown to increase the use of interpretation services (Behairy et al., 2023; Rajbhandari et al., 2021) and written resources (Isbey et al., 2022). For this project, a prospective QI design was based on the Model for Improvement (Institute for Healthcare Improvement [IHI], 2023). 9 The Model for Improvement was developed by the Associates in Process Improvement (IHI, 2023) and is used throughout healthcare as a framework for change initiatives. The model outlines the steps of team formation, setting aims, establishing measures, and selecting, testing, implementing, and spreading changes (IHI, 2023). This model was chosen because of its systematic and focused approach to healthcare QI projects. Specific Aims This Doctor of Nursing Practice (DNP) scholarly project aimed to address a health inequity experienced by Spanish-speaking patients at a women’s health clinic by improving clinic policies and practices related to communication and language-appropriate services. The project also aimed to demonstrate feasibility, usability, and satisfaction with interventions that promote the use of professional medical interpretation and language-appropriate written materials. Methods Context Valley Women’s Health (Valley) is a private practice women’s health organization with clinics throughout Utah. The American Fork Division is in Utah County and has three sites: American Fork, Lehi, and Saratoga Springs. Utah County is a predominately suburban county with approximately 702,500 residents (United States Census Bureau, n.d.). The providers include seven physicians, eight certified nurse-midwives, and twelve nurse practitioners who provide primary and specialized care to women of all ages. In addition, the clinic employs a large staff of registered nurses, medical assistants/certified nurse assistants, front desk personnel, ultrasound technicians, and lab technicians. Spanish-speaking providers include two physicians, one certified nurse-midwife, and one nurse practitioner. Spanish-speaking staff members include two receptionists, one registered nurse, and one medical assistant. 10 The patient population attending the clinics in the American Fork Division is predominately White and non-Hispanic. The largest minority group includes Hispanic women, many of whom speak Spanish as their first language. A flag in the electronic health record (EHR) marks a patient’s communication needs and preferences. Valley’s policy on interpretation services indicates that patients who prefer languages other than English should be offered the use of an interpreter at each visit. The video-based interpreter system, AMN®, is the primary means of interpretation for patients who speak languages other than English or are hearing impaired. There is no designated location or format for documentation of interpretation use. Staff and providers inconsistently document interpreter encounters, with some providing detailed information that includes the interpreter's name and reference number, while others simply note "interpreter used" or "interpreter refused." Additionally, there is no formal process for patients to decline interpretation services. Written materials consisting of intake forms, patient history forms, patient education handouts, and consent forms are available in English. A few of these forms and handouts have been translated into Spanish by uncertified, bilingual staff members. These Spanish forms are in various folders on a shared computer network drive. Interventions A DNP student led this QI initiative. The main collaborators were the CEO; Clinical Director; front office and clinical managers for the American Fork division; team lead for the American Fork midwifery group; and a Spanish-speaking medical assistant with a 30-year tenure at Valley. Valley’s Quality Committee, consisting of administration and selected provider representatives from sites across Utah, approved the proposed policy changes. Planning and Coordination 11 The project timeline (Figure 2) displays the progression of the project interventions. The first phase of the project included planning and data collection. Pre-implementation meetings with clinic management and providers were held to get ideas about current policies, practices, and problems. The project was presented to the physicians, nurse practitioners, and nursemidwives at the All-Provider meeting on October 17, 2023. Components of the CLAS standards were reviewed. A recent case review illustrated the importance of patients being scheduled with their provider of choice and the need for appropriate labeling of patient preference for bilingual providers or using interpretation. It was determined that clinic policies related to language services needed to be more comprehensive, and a language interpretation preference/refusal form needed to be created. Clinic policies were revised to comply with CLAS standards and legal requirements (Appendix A). A draft of a language interpretation preference/refusal form was created by clinic management. These two documents were presented to and approved by Valley’s quality committee. Continued planning meetings with clinic management produced additional ideas for interventions. A second alert flag was added to the EHR to clarify which Spanish-speaking patients preferred to see bilingual providers and which preferred interpreters. Additionally, the templates for frequently used notes were updated to include an option to mark “interpreter refused” or “interpreter was used” with a field to free-text the interpreter’s name and reference number. Data Collection A chart review was conducted with data from January 1, 2023, to October 15, 2023, by using a report from Valley’s EHR system that showed all patients with the original flag 12 indicating that they were Spanish-speaking. Each Spanish-speaking patient’s chart was reviewed for whether they had or had not seen a bilingual provider, as well as provider documentation of interpretation use or refusal. An initial report was created of patients with at least one instance of documentation regarding language interpretation. It was determined that this information was not specific enough, so each patient’s chart was reviewed again to indicate the number of clinic visits, the number of times the patient had seen a bilingual provider, and the number of times interpretation use had been documented. A second chart review was conducted with data from October 16, 2023, to January 29, 2024. This report included the original flag and the new one created to specify patients who requested professional medical language interpretation. Each clinic visit was reviewed to determine the use of a bilingual provider or professional language interpretation. A comprehensive review of all forms and handouts used in English was performed, and all available Spanish documents were gathered. Forms that had previously been translated by untrained personnel and English forms that were not available in Spanish, were sent to a professional medical language translation organization. Upon receipt of the translated documents (Appendix B), they were uploaded to an easy-to-access, central file location instead of the multiple random locations the few Spanish forms had previously occupied. Staff and Provider Assessment and Training The second phase of the project involved provider and staff assessment and training. It was determined that a succinct, explanatory workflow diagram would assist providers and staff in understanding appropriate language services that should be provided from the time a patient calls to schedule an appointment through their clinic visit. Appendix C shows the clinic workflow that was disseminated with training materials. An 8-minute training video was created 13 that outlined each step on the workflow, described the updated policies, and included information about the importance of language-appropriate care, correct use of video interpretation, and bilingual provider roles. Appendix D outlines the script that was used for the video. The training video and clinic workflow were sent to all staff and providers who work in the American Fork Division via AzovaTM, Valley’s internal messaging system, on November 15, 2023. The pre-implementation survey (Appendix E) was sent at the same time. Respondents were instructed to complete the survey immediately after watching the training video; thus, it assessed participants' perceptions and their understanding of the material in the video presentation. The survey remained open until December 14, 2023, with reminder messages sent the week before closure. The clinical manager had initially said they would send their own reminder messages and make the training mandatory but later said they could not do so because of time constraints. Implementation and Monitoring The third phase of the project included implementation and monitoring. Weekly rounding by the DNP student involved checking in with staff and providers to ask about services provided to Spanish-speaking patients and to troubleshoot problems in real-time. Staff and providers were asked if they had watched the training video, were using interpretation services, were using Spanish forms and handouts and knew how to find them, were encountering any problems, and had any other ideas for improving language services. Their responses were noted and categorized by theme. One-on-one training then reinforced clinic policies, particularly regarding appropriate documentation of language preference and interpretation use. Data was collected about the use of the iPad language interpretation system and the use of Spanish written resources. Plan-Do-Study- 14 Act (PDSA) cycles were implemented to address problems (Appendix F). Evaluation of the intervention in the fourth phase involved repeat data collection via chart review and survey as detailed in the Analysis section below. Study of the Interventions A pre-implementation survey (Appendix E) was administered at the start of the intervention to determine staff and provider perceptions and knowledge of the existing language services for Spanish-speaking patients. A post-implementation survey (Appendix G) revealed changes in practices and perceptions related to effectiveness, feasibility, usability, and satisfaction with the interventions. A chart review was done before and after the intervention to determine the use of bilingual providers and professional language interpreters during clinic visits. Change statistics and content analysis were used to determine if outcomes were related to the intervention. Rounding was performed weekly to reinforce the project interventions and support participants on an ongoing basis. Measures The 20-item pre-implementation survey (Appendix E) gathered participant demographic data, current participant perceptions and knowledge, use of language services for Spanishspeaking patients, and ideas for improving language services. The survey contained multiplechoice, Likert scale, and fill-in-the-blank type questions. The 19-item post-implementation survey (Appendix G) contained five knowledge and satisfaction questions that were similar to the questions in the first survey. Additional questions assessed the feasibility and usability of the project and its interventions. The participant responses on both surveys were anonymous, and the resulting data was unpaired. 15 The chart review collected data on the provision of language services with either a bilingual provider or a professional language interpreter for a sample of Spanish-speaking patients. The sample included all American Fork Division patients with a flag in their chart indicating they spoke Spanish. Each patient visit was reviewed to see whether a bilingual provider or professional language interpreter was used. The initial chart review was conducted twice to ensure the completeness and accuracy of the data. Methods used to promote the reliability of the data included a review of surveys by multiple professionals within the organization and faculty members to ensure high-quality questions were included to determine feasibility, usability, and satisfaction. Ongoing assessment was conducted during weekly rounding sessions and via PDSA cycles. Completeness and accuracy of data were ensured by using the RedCap data management system. Data summaries and analyses were compiled with consultation by a statistician. Analysis Chart Review The chart review was analyzed with descriptive and interpretative statistics. A report of all patients with the designated “Spanish” flag was generated after the implementation period and reviewed for interpretation documentation and use. Comparative analysis with a chi-square test of independence determined changes in documentation patterns. Participant Surveys Demographic data was collected on the pre- and post-implementation participant survey. Demographic variables were described using appropriate summary statistics. Descriptive statistics were employed to characterize the data collected from both the pre- and postimplementation surveys. Comparative data was analyzed with the Mann-Whitney Rank test due 16 to unpaired pre-and post-data. The open-ended responses were read word-for-word, categorized, and assessed for themes. Weekly Rounding Analysis of data collected during weekly rounding used a PDSA cycle format to determine what further interventions were needed. Notes were taken during weekly rounding, and a descriptive analysis was conducted. Content analysis was performed by analyzing notes line-by-line to develop common categories and sub-categories. These categories were organized and summarized to form common themes from staff and provider responses. Ethical Considerations This QI project was not subject to the University of Utah Institutional Review board oversight. There were no conflicts of interest concerning this study. Results Table 1 summarizes the data collected from the EHR review. This chart review aimed to determine if language services were provided during clinic visits with either bilingual providers or professional language interpreters via the iPad application. There were 299 clinic visits for patients with the designated flag for Spanish speakers during the baseline, pre-implementation period, January 1, 2023, to October 15, 2023, for an average of 7.3 weekly visits. Of these visits, 36.1 % (N=108) were with bilingual providers, and 23.7% used professional language interpreters (N=71). The remaining 120 visits, or 40.1% of all clinic visits, did not document the provision of language services. A second chart review collected data for the implementation period of October 16, 2023, to January 29, 2024. There were 118 visits designated by the flags for Spanish speakers, an average of 7.9 visits per week. Bilingual providers were used for 52.5% of these visits (N=62), 17 and professional language interpreters were used for 32.2% (N=38). The remaining 15.3% (N=18) did not provide language care through interpretation or bilingual providers. An audit of all Spanish-language forms and handouts at the beginning of the project showed that nine forms were used consistently. These forms were stored in at least four different computer file locations, and none of the staff, providers, and management had been aware of all of these locations. After the audit and professional translation of available forms and handouts, the resulting thirty-one patient forms and handouts were stored in one central file location. The available written resources in Spanish more than tripled (244% increase) as a result of the project. The pre-implementation survey was sent to 138 staff and providers and 35 voluntarily responded for a response rate of 25.4%. Their demographic data is summarized in Table 2 and response statistics are reported in Table 3. Over half of the respondents (57.1%) were clinical staff, including assistants, nurses, and technicians; 37% were providers, and 5.7% were front office staff. Most participants had been employed with Valley for 1-10 years, were 18 to 54 years old, and were White and non-Hispanic. Only 11.4% of the sample indicated they could communicate comfortably in Spanish. Most respondents (80.0%) were satisfied with professional interpretation services and the available forms and handouts in Spanish (76.4%). They also reported being able to identify patients who needed interpretation (82.4%), knowing where to document interpretation use (80%), and knowing where to find Spanish forms and handouts (77.1%). Respondents positively perceived using interpretation services and Spanish forms and handouts to improve care for Spanish-speaking patients. However, results were mixed on using ad hoc interpreters instead of professional interpreters via iPad; 25.7% favored using staff members, and 17.1% favored using 18 family. Respondents were confident in Valley’s policies for interpretation services (100%). They indicated that the video helped them understand their role (100%) and would make it easier to provide high-quality care for Spanish-speaking patients (100%). Participants’ free-text responses for improving language services included emailing Spanish intake forms before visits, hiring more bilingual medical staff, and including a statement that interpretation services are available on the company website. The post-implementation survey was sent to 138 staff and providers via AzovaTM and 32 responded, for a response rate of 23.2%. Included in the message were links to the training video and clinic workflow. The purpose of the survey was to determine the staff and provider satisfaction with the project and the feasibility and usability of its interventions. A majority (65.5%) of respondents participated in the first survey, although the survey participants were unmatched despite having similar demographics, as seen in Table 2. Table 4 reports response percentages. Most participants were satisfied with professional interpretation services (67.8%) and the available forms and handouts in Spanish (75%). As in the first survey, they indicated being able to identify patients needing interpretation (78.2%), knowledge of where to document interpretation use (67.8%), and knowledge of where to find Spanish forms and handouts (87.5%). Many participants reported using professional language interpretation (65.7 %), but only 37.6% reported using it often. However, 78.1% of respondents used Spanish forms and handouts, and 61.3% used them frequently. Only 46.9% of participants reported using the new interpretation refusal form approved by Valley’s quality committee. According to 93.6% of post-implementation survey respondents, the project improved services for Spanish-speaking patients. A chi-square test of independence showed a significant 19 association between the project interventions and the provision of language care, X2 (1, N = 417) = 22.57, p < .00001. The specific interventions to increase staff and provider awareness of the project’s objectives included weekly rounding drop-in visits and word-of-mouth from other staff and providers. The language services training video, clinic workflow document, and reminder cards on computer stations were also deemed helpful. Write-in ideas for further interventions included increased availability of forms and handouts in other languages, continued training for the front desk on the use of appropriate forms, hiring more Spanish-speaking front office staff, making iPads available for the front office, and more consistent use of the flags to tag patients as needing an interpreter (Table 4). The qualitative rounding data is summarized in Table 5. Staff and providers admitted to using family members to interpret per patient request but did not use the interpretation refusal form created for these situations. Most had no technical issues with the iPad app or equipment used for video interpretation. Providers indicated that they appreciated having the “interpreter used” or “interpreter refused” statements added to frequently used templates for clinical notes. Qualitative rounding data made it clear that many staff and providers had not watched the training video because they had not received it and/or that they had not retained the information presented in it about the new file pathway for Spanish written materials. One-on-one training was provided to demonstrate locating the correct file location. Ideas obtained during rounding were tested during PDSA cycles, resulting in reminder cards being placed on workstations (Appendix F). When staff and providers could find the forms and learned that many more were available in Spanish, they reacted with approval and satisfaction. During weekly rounding, a lab staff member mentioned the idea to create cards with frequently used phrases in Spanish for use during blood draws. The laminated cards that were 20 created were well-received by all lab technicians and the lab supervisor, and their use was tested with a PDSA cycle, as shown in Appendix F. However, several weeks after their implementation, they had only been used once, and the lab technician reported that the patient seemed confused by them. Weekly rounding revealed that the one bilingual nurse at the American Fork location was accruing excessive overtime as she attempted to field phone concerns and follow-up for Spanishspeaking patients. Appendix F shows the PDSA cycle that was applied to create a small team of bilingual nurses from other Valley locations. The team's formation successfully reduced overtime by the one bilingual nurse, while continuing to provide quality nursing triage. Discussion Summary Staff and providers indicated that this QI project improved language services for Spanishspeaking patients. The project interventions resulted in more visits with bilingual providers and increased documented professional language interpreter use. Satisfaction with the additional professionally translated Spanish forms and handouts was evident. This project shows that the aim of increasing the use of language interpreters and written Spanish resources can be realized with a strategic implementation plan. Interpretation The second chart review revealed a significant increase in visits with bilingual providers and the use of professional language interpreters. Bilingual provider visits increased by 45% and visits where interpretation was offered increased by 36%. It cannot be said with certainty whether the increase in professional language interpreters is from an increase in documentation or actual use, as this could not be ascertained from the data. However, increasing visits with 21 bilingual providers is an objective measure of increased language-appropriate care provided to Spanish speakers and is in harmony with the project objectives. The cause of the increase in language-appropriate care could be from several different factors. The addition of the flag that specified patients who required interpreter use could have raised awareness to provide language services for these patients. Providers remarked that they appreciated having the field related to interpreter use added to frequently used clinical note templates. The entry was placed at the top of the note in a prominent location that was easy to find and served as a reminder for documentation. However, it was found that this field was sometimes filled in by the medical assistant instead of the provider, making it difficult to verify if both the medical assistant and provider used the interpreter for their part of the patient interaction. The increased scheduling of patients with bilingual providers could have resulted from increased front office staff awareness. The training video and individual communications with staff provided information about who the bilingual providers were. From discussions with patients, it was found that knowledge of these providers was spreading by word-of-mouth among Hispanic families and communities. This might also have contributed to the increase in average visits of Spanish speakers per week from 7.3 to 7.9. This increase in new patients to the clinic likely increased revenue, although a profit analysis was not conducted. However, profits may have been lessened by the cost associated with professional language interpreter use. The lack of association between the project interventions and post-implementation survey results is notable, as seen in Table 6. None of the Mann-Whitney U-values for the five questions that monitored pre- and post-satisfaction, feasibility, and usability showed a statistical association. This could be because of the high satisfaction and knowledge rates reported on the 22 pre-implementation survey. These high rates of satisfaction and knowledge related to professional language interpreters and available Spanish forms and handouts were surprising because of the many complaints and concerns raised prior to the implementation of the project. However, since the pre-survey was sent immediately after the training video that presented the new workflow for language services, the high satisfaction rates were likely related to the new plan rather than satisfaction with prior or current language services. Some of the survey questions only applied to some of the participants who completed it. For example, ultrasound technicians do not routinely use patient forms or handouts, so their responses were anticipated to be negative and could have influenced overall results. Additionally, each staff member and provider use different forms for their respective roles, so their perceived feasibility and usability would differ. The survey was not versatile enough to capture these differences. It is reassuring that 93.6% of the post-implementation survey respondents indicated that the project was instrumental in improving language services at the clinic. Qualitative data from weekly rounding demonstrated the feasibility and usability of the tools and resources brought forth through this project. Staff and providers were particularly satisfied with the availability of more forms and handouts in Spanish. It is concerning to note that only 46.9% of respondents reported using the new interpretation refusal form that Valley’s quality committee approved, representing a persistent liability issue that has not been addressed. The outcomes of this project help fill a gap in the existing evidence regarding strategies for overcoming language barriers, specifically for Spanish-speaking women. The project confirms the results of other QI projects that have demonstrated interventions that improve the use of interpreters (Behairy et al., 2023; Rahbhandari et al., 2021). 23 Limitations There are several limitations for this project that require consideration. Valley Women’s Health is located in Utah County, which has a high proportion of White residents as reflected in the demographics of survey participants. This homogeneity may limit the generalizability of the study in areas with diverse staff and providers, and therefore, our results may not reflect all healthcare workers specializing in outpatient maternity and women’s healthcare. Several factors limited the chart review. The EHR report contained all patients seen in the American Fork division with the flag designated for Spanish-speakers and those needing interpretation. Patients for whom the flag had been accidentally omitted would not have been included. Some patients may have been included because they were Hispanic with suspected limited English proficiency when they did not require language assistance. This would have skewed the data, making it seem like language should have been provided when it wasn’t needed. The chart review of interpretation use was dependent on the documentation of use. There were perhaps instances when interpretation was used but not documented. It was not possible to determine how often that might have occurred. The survey results may have been limited by volunteer bias, as the participants were not randomly selected. The results may not represent all staff and providers due to the relatively low response rate of 25.4%. The data may be further limited by the pre- and post-surveys being unpaired. Additionally, the dissemination method was problematic as many staff stated they had not seen the messages about the surveys and training materials. The AzovaTM app had intermittent functionality issues with pushing notifications through to devices. This could have significantly decreased the number of completed surveys received. 24 One dimension that should have been measured was the language competency of bilingual providers. Research findings suggest this is integral to providing language-appropriate care (Diamond et al., 2019). Providers at the clinic self-select whether they consider themselves able to conduct visits in Spanish. However, there seems to be an informal evaluation process by other bilingual staff and providers that confirms they are proficient. Further QI efforts should address this by assessing bilingual providers' language competence and proficiency with validated tools. Conclusions The population of Hispanic women in Utah is expected to increase. Many Hispanic women may have limited English proficiency, necessitating appropriate language accommodations. Outpatient clinics may not have adequate services in place for these accommodations, or they may not be used appropriately. Our QI project shows that strategic interventions can improve the use of professional language interpreters and Spanish written resources. These interventions are acceptable, feasible, and easy to use. The project resulted in tangible products that were implemented into the clinic’s day-today operations. The updated clinic policy, the training video, the modified clinical notes templates, and the professionally translated forms and handouts are now integrated into the normal workflow of the American Fork division. As such, these interventions are hoped to be sustainable and will continue. An executive summary (Appendix I) and presentation of the outcomes were given to Valley’s administration and clinical management. They indicated their plan to expand the changes to other divisions across Utah within Valley Women’s Health. The executive summary (Appendix I) included recommendations for clinic management and administration to reinforce the importance of following CLAS standards. Key 25 recommendations included utilizing the training video for onboarding new staff and providers and periodic refresher training sessions. Additionally, regular audits might be necessary to ensure proper documentation of interpretation use and use of Spanish written resources. Acquiring additional iPads designated for interpretation by front office staff would further facilitate interactions with Spanish-speaking patients. The organization should consider increasing the number of bilingual staff and providers. However, the administration is encouraged to ensure the language proficiency of bilingual providers with competency assessments. To improve accessibility, adding a statement on the clinic website about the availability of professional medical interpretation services for patients with limited English proficiency is recommended. Lastly, emailing Spanish intake forms to patients before their visits would streamline processes and enhance patient experience. Further study is needed to determine patient satisfaction with the language services provided at the clinic. A comparative analysis of patient preference for bilingual providers versus professional language interpreters via video would be beneficial. Measurement of clinical outcomes could be used as an indicator of the effectiveness of communication and written resources. Funding The Dick & Timmy Burton Scholarly Project Scholarship funds were utilized to assist with providing incentives for survey completion, obtaining professionally translated written resources in Spanish, and presenting project results at a nursing conference. Acknowledgments The author would like to acknowledge Dr. Ben Becker, DNP, for being the content expert for this project. Additional thanks go to Heidi Norman, Lauren Pearson, Kelly King, and Adam 26 Rasmussen, who work in management and administration at Valley Women’s Health and have helped support the project initiatives. Kathryn Seamons, CNM, WHNP-BC, Midwife Team Lead, and the other members of the midwifery group were exceptionally supportive in reviewing the project plans and materials. Mirta Diaz, CNA, deserves special thanks for her efforts on behalf of this project and for advocating for Spanish-speaking patients at Valley Women’s Health for almost 30 years. 27 References Ali, P. A., & Watson, R. (2018). Language barriers and their impact of provision of care to patients with limited English proficiency: Nurses perspective. Journal of Clinical Nursing, 27, e1152–e1160. https://doi.org/10.1111/jocn.14204 Behairy, M., Alenchery, A., Cuesta-Ferrino, C., Bhakta, H., & Zayas-Santiago, A. (2023). Increasing Language Interpreter Services Use and Documentation: A Quality Improvement Project. The Journal for Healthcare Quality (JHQ), 45(1). Civil Rights Act of 1964, Pub. L. No. 88-352, 78 Stat. 241 (1964). https://www.govinfo.gov/app/ details/COMPS-342 Comfort, Jain, M., Wu, H., & Nathan, L. (2023). Rate of primary Cesarean delivery by language preference among nulliparas. American Journal of Perinatology. https://doi.org/10.1055/a-2008-8540 De Alba Rosales, A., Schober, D., & Johansson, P. (2020). Examining Perceptions of Spanish Language Health Information Among Hispanics Living in the United States: A Qualitative Study Assessing Videos, Brochures, and Websites. Health Promotion Practice, 22(3). Diamond, L., Izquierdo, K., Canfield, D., Matsoukas, K., & Gany, F. (2019). A Systematic Review of the Impact of Patient–Physician Non-English Language Concordance on Quality of Care and Outcomes. Journal of General Internal Medicine, 34(8), 1591–1606. https://doi.org/10.1007/s11606-019-04847-5 Institute for Healthcare Improvement. (2023). How to improve. Retrieved November, 7, 2023 from https://www.ihi.org/resources/how-to-improve Isbey, S., Badolato, G., & Kline, J. (2022). Pediatric Emergency Department Discharge Instructions for Spanish-Speaking Families: Are We Getting It Right? Pediatric 28 Emergency Care, 38(2). https://journals.lww.com/peconline/Fulltext/2022/02000/Pediatric_Emergency_Department_Discharge.93.aspx Jang, M., Plocienniczak, M. J., Mehrazarin, K., Bala, W., Wong, K., & Levi, J. R. (2018). Evaluating the impact of translated written discharge instructions for patients with limited English language proficiency. International Journal of Pediatric Otorhinolaryngology, 111, 75–79. https://doi.org/10.1016/j.ijporl.2018.05.031 Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007, April). Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 42(2), 727+. Gale Academic OneFile. Kem C. Gardner Policy Institute. (n.d.). Experimental population projections. David Eccles School of Business, University of Utah. Retrieved September 28, 2023, from https://gardner.utah.edu/demographics/projections/experimental-population-projections/ Office of Health Equity. (2022). A snapshot of current racial and ethnic health disparities in Utah. Utah Department of Health and Human Services. Salt Lake City, Utah. http://healthequity.utah.gov/data-and-reports/ Office of Health Equity. (2023). Twenty years of health data for Hispanic/Latino communities in Utah. Salt Lake City, UT: Utah Department of Health and Human Services. Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stat. 119 (2010). https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf Rajbhandari, P., Keith, M. F., Braidy, R., Gunkelman, S. M., & Smith, E. (2021). Interpreter Use for Limited English Proficiency Patients/Families: A QI Study. Hospital Pediatrics, 11(7), 718–726. https://doi.org/10.1542/hpeds.2020-003889 29 Schwei, R. J., Schroeder, M., Ejebe, I., Lor, M., Park, L., Xiong, P., & Jacobs, E. A. (2018). Limited English Proficient Patients’ Perceptions of when Interpreters are Needed and how the Decision to Utilize Interpreters is Made. Health Commun, 33(12), 1503–1508. https://doi.org/10.1080/10410236.2017.1372047 Soulages Arrese, N., Cooper, M. T., White, A., Chen, S., & DeLeon, S. (2021). Creating a Tool to Assess Interpretive Services Perceptions at a Hospital System Level. Journal of Immigrant and Minority Health, 23(5), 1116–1120. Togioka, Seligman, K. M., & Delgado, C. M. (2022). Limited English proficiency in the labor and delivery unit. Current Opinion in Anaesthesiology, 35(3), 285–291. https://doi.org/10.1097/ACO.0000000000001131 United States Census Bureau. (n.d.). QuickFacts: Utah County, Utah. Retrieved November 7, 2023, from https://www.census.gov/quickfacts/fact/table/utahcountyutah/PST045222 U.S. Department of Health and Human Services. (2017). Section 1557: Frequently asked questions. Retrieved February 28, 2024 from https://www.hhs.gov/civil-rights/forindividuals/section-1557/1557faqs/index.html#:~:text=In%20what%20ways %20does%20Section,%2C%20sex%2C%20age%20or%20disability. 30 Table 1 Use of bilingual providers and professional language interpreters Baseline period Implementation period (1/1/2310/15/23) 10/16/231/29/24) N (%) N (%) Number of Spanish-speaking patients seen in American Fork division 110 69 Total number of visits for Spanish-speaking patients 299 118 Number of visits with bilingual provider only 108 (36.1) 62 (52.5) Number of visits with documented interpreter use 71 (23.7) 38 (32.2) Number of visits with no language care (not seen by bilingual providers and no documented interpreter use or refusal) 120 (40.1) 18 (15.3) 16 20 Number of visits with both bilingual providers and documented interpreter use or refusal 31 Table 2 Staff and Provider Participant Demographics: Pre- and Post-Implementation Surveys Job Title Front office staff Medical assistant/Certified nursing assistant Lab technician Ultrasound technician Registered nurse Certified nurse-midwife Nurse practitioner Physician Years Employed at Clinic Less than one year 1-5 years 6-10 years 10+ years Missing Age 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65+ years Missing Ethnicity Hispanic or Latino(a) Non-Hispanic Missing Race White Black or African American Native American or Alaska Native Asian Native Hawaiian or other Pacific Islander Pre-Implementation N=35 (%) Post-Implementation N= 32 (%) 2 (5.7) 6 (17.1) 4 (11.4) 3 (8.6) 7 (20.0) 6 (17.1) 5 (14.3) 2 (5.7) 6 (18.8) 6 (18.8) 2 (6.3) 2 (6.3) 4 (12.5) 6 (18.8) 5 (15.6) 1 (3.1) 10 (29.4) 12 (35.3) 10 (29.4) 2 (5.9) 1 (2.9) 6 (19.4) 13 (41.9) 6 (19.4) 6 (19.4) 1 (3.1) 9 (26.5) 7 (20.6) 8 (23.5) 5 (14.7) 3 (8.8) 2 (5.9) 1 (2.9) 10 (31.3) 7 (21.9) 4 (12.5) 6 (18.8) 4 (12.5) 1 (3.1) 0 2 (5.9) 32 (94.1) 1 (2.9) 2 (6.3) 30 (93.8) 0 33 (94.3) 0 0 1 (2.9) 1 (2.9) 31 (96.9) 0 0 0 1 (3.1) 32 Table 3 Pre-Implementation Survey Results N=35 (%) Choose the response that best describes your ability to communicate with Spanishspeaking patients. I don’t know any Spanish at all 22 (62.9) I can understand and/or speak a little Spanish 8 (22.9) I can understand and/or speak in Spanish most of time 1 (2.9) I can communicate comfortably with Spanish-speaking patients without the help of an interpreter, patient's family member, or staff member 4 (11.4) I am satisfied with the professional medical interpretation services that are available via the iPads. Strongly disagree 1 (2.9) Disagree 0 Neither agree nor disagree 6 (17.1) Agree 22 (62.9) Strongly agree 6 (17.1) I can identify which patients need professional medical interpretation by looking at their charts on Greenway. Strongly disagree 0 Disagree 3 (8.8) Neither agree nor disagree 3 (8.8) Agree 17 (50) Strongly agree 11 (32.4) Missing 1 (2.9) I know where to document the use of professional medical interpretation for encounters with Spanish-speaking patients. Strongly disagree 0 Disagree 4 (11.4) Neither agree nor disagree 3 (8.6) Agree 16 (45.7) Strongly agree 12 (34.3) 33 Patients who prefer to speak Spanish get better care when professional medical interpretation is used. Strongly disagree 0 Disagree 0 Neither agree nor disagree 0 Agree 12 (34.3) Strongly agree 23 (65.7) It is easy to use the iPads for professional medical interpretation. Strongly disagree 0 Disagree 1 (2.9) Neither agree nor disagree 11 (31.4) Agree 13 (37.1) Strongly agree 10 (28.6) Using staff members to interpret for me is more effective than the professional medical interpretation on the iPad. Strongly disagree 3 (8.6) Disagree 10 (28.6) Neither agree nor disagree 13 (37.1) Agree 6 (17.1) Strongly agree 3 (8.6) I can deliver high quality care using a family member to translate instead of professional medical interpretation. Strongly disagree 4 (11.4) Disagree 14 (40.0) Neither agree nor disagree 11 (31.4) Agree 6 (17.1) Strongly agree 0 I am satisfied with the Spanish patient forms and handouts I currently have access to. Strongly disagree 1 (2.9) Disagree 3 (8.8) Neither agree nor disagree 4 (11.8) 34 Agree 10 (58.8) Strongly agree 6 (17.6) Missing 1 (2.9) I know where to find patient information or handouts in Spanish that I can provide to my patients. Strongly disagree 1 (2.9) Disagree 4 (11.4) Neither agree nor disagree 3 (8.6) Agree 20 (57.1) Strongly agree 7 (20.0) I feel that having patient handouts in Spanish helps me provide high-quality care for my Spanish-speaking patients. Strongly disagree 0 Disagree 0 Neither agree nor disagree 4 (11.4) Agree 12 (34.3) Strongly agree 19 (54.3) I feel confident in my understanding of the interpretation services policy at Valley Women’s Health. Strongly disagree 0 Disagree 0 Neither agree nor disagree 0 Agree 17 (50.0) Strongly agree 17 (50.0) Missing 1 (2.9) The video helped me to understand my role in using interpretation services appropriately. Strongly disagree 0 Disagree 0 Neither agree nor disagree 0 Agree 13 (37.1) Strongly agree 22 (62.9) 35 The information in the video will make it easier for me to provide high-quality care for my Spanish-speaking patients. Strongly disagree 0 Disagree 0 Neither agree nor disagree 0 Agree 15 (42.9) Strongly agree 20 (57.1) Please use the box to write any other ideas for improving the language services we provide to Spanish-speaking patients. Email Spanish intake forms to patients before the visit Hire more medical staff that are bilingual Have website state that we have language interpretation available 36 Table 4 Post-Implementation Survey Results N=32 (%) Did you complete the first survey that was sent out about this project that accompanied the training video? Yes 21 (65.6) No 6 (18.8) I don’t remember 5 (15.6) Can you identify which patients need professional language interpretation by looking at their charts on Greenway? Strongly disagree 0 Disagree 3 (9.4) Neither agree nor disagree 4 (12.5) Agree 18 (56.3) Strongly agree 7 (21.9) Missing 1 (2.9) If you use the iPad/phone system for professional language interpretation, do you know where to document it? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 4 (12.9) 2 (6.5) 4 (12.9) 11 (35.5) 10 (32.3) If a patient refuses professional language interpretation, do you use the new refusal form created by Valley’s quality committee? Strongly disagree 5 (15.6) Disagree 5 (15.6) Neither agree nor disagree 7 (21.9) Agree 11 (34.4) Strongly agree 4 (12.5) Are you satisfied with the iPad/phone system professional language interpretation service? 37 Strongly disagree 1 (3.2) Disagree 2 (6.5) Neither agree nor disagree 7 (22.6) Agree 14 (45.2) Strongly agree 7 (22.6) Do you use Spanish patient forms and handouts for Spanish-speaking patients? Strongly disagree 1 (3.1) Disagree 0 Neither agree nor disagree 6 (18.8) Agree 12 (37.5) Strongly agree 13 (40.6) If so, how often do you use them for Spanish-speaking patients? Never 3 (9.7) Rarely 4 (12.9) Occasionally 5 (16.1) Frequently 8 (25.8) Always 11 (35.5) Missing 1 (3.1) Do you know where to find Spanish patient forms and handouts? Strongly disagree 2 (6.3) Disagree 2 (6.3) Neither agree nor disagree 0 Agree 15 (46.9) Strongly agree 13 (40.6) Are you satisfied with the Spanish patient forms and handouts that are available? Strongly disagree 1 (3.1) Disagree 0 Neither agree nor disagree 7 (21.9) Agree 8 (25.0) Strongly agree 16 (50.0) 38 Which of the following interventions from this project helped you know how to provide appropriate services to Spanish-speaking patients? (Select all that apply) Language services training video 12 (40.0) Clinic workflow document 12 (40.0) Reminder cards on computer stations 12 (40.0) Drop in visits 13 (43.3) Reminder texts from your manager 3 (10.0) Word-of-mouth from other staff/providers 13 (43.3) Missing 2 (6.3) Do you think this project’s interventions have improve language services for Spanish-speaking patients? Strongly disagree 0 Disagree 0 Neither agree nor disagree 2 (6.5) Agree 14 (45.2) Strongly agree 15 (48.4) Missing 1 (3.1) Please use the box to write any other ideas for improving the language services we provide to Spanish-speaking patients. Increased number of documents in Spanish is useful and beneficial to patients Assigning triage to Spanish-speaking nurses benefits patients and patients love it 4 (12.9) 1 (3.1) The front desk needs more Spanish-speaking staff and/or their own dedicated iPads to use the interpretation system 2 (6.5) More training needed 2 (6.5) The iPad system doesn’t always work properly 1 (3.1) Need to add appropriate flags to patients charts consistently 2 (6.5) 39 Table 5 Weekly Rounding Data Theme Quotes The training video “The video was helpful. I have added the file pathway for the Spanish forms and handouts to my favorites” Frequency N=30 (%) 2 (6.7) “The video was good but mostly geared to the MA’s and receptionists” 1 (3.3) “I didn’t get a message about a training video” 5 (16.7) Use of professional language interpretation “I didn’t use the interpreter because the patient asked me to use her husband instead” 4 (13.3) Use of Spanish forms and handouts “The receptionist didn’t give the patient the new Spanish intake form” 4 (13.3) “I tried finding the new forms but they weren’t in the usual file folder” 9 (30) “I didn’t know we had all our forms translated into Spanish” 3 (10.0) “The reminder cards on our computers are really helpful” 6 (20.0) “It would be great if we had a paper with frequently used phrases to show Spanish patients instead of getting the interpreter” 5 (16.7) “The file for Spanish forms would be easier to find if it could be added to our starred files on Greenway” 3 (10.0) Additional training needed Ideas for improving language services 40 Table 6 Survey Results Comparison Pre N=35 (%) Post N= 32 (%) Satisfaction with professional medical interpretation services Strongly disagree 1 (2.9) 1 (3.2) Disagree 0 2 (6.5) Neither agree nor disagree 6 (17.1) 7 (22.6) Agree 22 (62.9) 14 (45.2) Strongly agree 6 (17.1) 7 (22.6) Mann-Whitney U-value = 9.5. Critical value of U at p<.05 = 2 Identification of which patients need interpretation by looking at chart Strongly disagree 0 0 Disagree 3 (8.8) 3 (9.4) Neither agree nor disagree 3 (8.8) 4 (12.5) Agree 17 (50) 18 (56.3) Strongly agree 11 (32.4) 7 (21.9) Missing 1 (2.9) 1 (2.9) Mann-Whitney U-value = 11.5. Critical value of U at p<.05 = 2 Knowledge of where to document interpretation use Strongly disagree 0 4 (12.9) Disagree 4 (11.4) 2 (6.5) Neither agree nor disagree 3 (8.6) 4 (12.9) Agree 16 (45.7) 11 (35.5) Strongly agree 12 (34.3) 10 (32.3) Mann-Whitney U-value = 12. Critical value of U at p<.05 = 2 Satisfaction with available Spanish patient forms and handouts Strongly disagree 1 (2.9) 1 (3.1) Disagree 3 (8.8) 0 Neither agree nor disagree 4 (11.8) 7 (21.9) Agree 10 (58.8) 8 (25.0) 41 Strongly agree 6 (17.6) 16 (50.0) Missing 1 (2.9) 0 Mann-Whitney U-value = 11.5. Critical value of U at p<.05 = 2 Knowledge of where to find patient information or handouts in Spanish Strongly disagree 1 (2.9) 2 (6.3) Disagree 4 (11.4) 2 (6.3) Neither agree nor disagree 3 (8.6) 0 Agree 20 (57.1) 15 (46.9) Strongly agree 7 (20.0) 13 (40.6) Mann-Whitney U-value = 10. Critical value of U at p<.05 = 2. 42 Figure 1 National Culturally and Linguistically Appropriate Services Standards Communication and Language Assistance 1. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 2. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 3. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 4. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. 43 Figure 2 44 Appendix A Revised Clinic Policy for Interpretation Services INT ERPRET A T ION SERVICES POLICY Legal Requ i r em en t s Medical offices are legally required to provide professional medical interpretation for any patient with limited English proficiency. A medical interpreter is defined as a bilingual or multilingual person with the appropriate training to provide real-time translations between healthcare professionals and patients or their family members in person, over the phone or via video for complicated communications. Valley meets these requirements using our video interpretation system*, AMN Healthcare. AMN Healthcare meets the legal requirements needed for proper medical interpretation. In t er p r et er Sy st em An interpreter should be used for each in-person visit, telehealth visit, or any phone call pertaining to a patient’s medical care (this includes, but is not limited to, test results, medical questions/answers or medical recommendations). Every interaction using our interpreter system should note the reference number provided by the interpreter at the beginning of the call. Im por t ance Of Usin g A Cer t if ied Int er p r et er Using a translator that is medically certified is highly recommended for a few reasons. The most important reason being to make sure that we are not only meeting the legal requirements, but that our patients receive the most accurate information while under our care. In the event that there was a miscommunication between a patient and us regarding her health, we can contact AMN using the reference number for the interaction to get information on where the issue was. Family members or friends of the patient are not recommended to translate for a patient. Bilingual staff members that are not certified as a medical interpreter are not recommended to translate for patients. Appropriate medical translation requires additional training/certification. Bi li ngual St af f / Pr ov i der s and/ or Ref usal of Int er pr et at i on Ser v i ces All patients that do not speak English fluently should be offered a medical interpreter using our interpreter, but may choose to decline. If they decline, a refusal form should be signed, dated, and scanned to the patient’s chart. The patient may change their preference for interpretation services at any time. Non-interpreter bilingual staff members may provide direct care to their own assigned patients within the scope of their usual job responsibilities. Patients should be offered a medical interpreter, but may choose whether they wish to work with bilingual providers and staff or use a medical interpreter. If they choose this option, a refusal form should be signed. If the patient is offered via phone call, it should be noted clearly in the phone call note that the patient refused an interpreter and wanted to speak with a non-certified bilingual staff member. Updated by QA Committee October 2023 45 Appendix B List of Available Handouts and Forms in Spanish Baseline Forms/Handouts Added During Implementation Generic Procedure Consent Form CNM childbirth class handout Annual History form Contraception options Infertility medications instructions Depression during and after pregnancy handout Intake form EPDS screener IUD consent form (not professionally translated) Endometrial biopsy consent form Major GYN surgery consent form GAD 7 screening Prenatal intake form GBS information handout Sterilization consent Glucola alternatives VBAC consent form Glucose test instructions Hysteroscopy consent form In office IV therapy consent form In office vaginal repair consent form Induction of labor handout Informed refusal Insomnia patient education handout Interpretation refusal Labor signs handout LEEP consent Mental health intake Methotrexate- what to expect handout Minor surgery laparoscopy consent form Minor surgery hysteroscopy consent form Miscarriage treatment options Nexplanon consent form Pelvic floor exercises patient handout Pelvic girdle pain Pre-diabetes patient education handout Pregnancy booklet Rhogam in office consent Semen analysis information TDAP information sheet 46 Appendix C Clinic Workflow Diagram Valley Women’s Health Workflow: Services for Spanish-Speaking Patients Scheduling Spanishspeaking patients call or chat to schedule appointment FRONT OFFICE STAFF • Spanish-speaking receptionists schedule appointments whenever possible • English-speaking receptionists use iPad interpreter • Ask about preference for professional interpretation or Spanish-speaking provider and inform them that they will need to sign a refusal form if they decline interpretation • Add extra 10 minutes to clinic visits that require interpretation • Add ”Spanish” flag to chart if Spanish-speaking provider preferred. Add ”No English” flag if interpreter is preferred Triage Spanishspeaking patients call or chat with questions NURSING STAFF • Patients are asked if they prefer to use interpretation or speak to nurse in Spanish. Document if they decline interpretation • Tasks, Azova messages, and voicemails are routed to Spanish-speaking nurses for patients with ”Spanish” flag • Interpretation is used for all other encounters including URGENT matters that should not be delayed until a Spanishspeaking provider is available Clinic Visits FRONT OFFICE STAFF • Spanish-speaking receptionists wear “Se habla español” badge and place “Se habla español” sign at their station • When checking patient in, administer interpretation preference/refusal form as needed • Use Spanish forms and handouts Spanishspeaking patient presents to clinic MEDICAL ASSISTANT/CERTIFIED NURSE ASSISTANT • Prior to appointment: check iPad and ensure it is working. Troubleshoot problems. Reach out to clinical management PRN. If iPad cannot be set up, use phone interpreter service • Use interpretation to obtain information needed for the appointment • Use Spanish forms and handouts • Ensure iPad is ready and in exam room for provider to use • Document the reference number or refusal in the prenatal flowsheet or note PROVIDERS • Use iPad or phone interpretation for the visit • Check to make sure reference number or refusal has been appropriately documented in prenatal flowsheet or note • Use Spanish forms and handouts • Spanish-speaking providers use interpretation and document reference number to obtain consent for surgery, or for sensitive and/or high acuity visits LAB TECHNICIANS • Lab tech gives patient a laminated instruction card and/or plays prerecorded audio message to obtain needed verification information • If the patient seems uncomfortable or has questions, lab tech will use iPad or phone interpretation to answer their questions ULTRASOUND TECHNICIANS • Prior to appointment: check iPad and ensure it is working. Troubleshoot problems. Reach out to clinical management PRN. If iPad cannot be set up, use phone interpreter service • Use iPad or phone interpretation for the visit Reminders • • • • When using video or phone interpretation, speak directly to the patient, not the interpreter Interpretation use or refusal needs to be documented with each patient encounter Bilingual clinical staff who are not assigned to a patient’s care cannot interpret for another person unless they have passed a certification exam (currently, none of our staff are certified) Bilingual staff and providers may provide direct care for patients they are assigned to, within their scope of responsibility 47 Appendix D Training Video Script (Title slides) Hello everyone! I’m Erica Nelson. I’m a midwife and women’s health nurse practitioner and I’ve been with Valley for 9 years now. I’m pursuing a Doctor of Nursing Practice degree at the University of Utah and am partnering with Valley to do a quality improvement project to address language barriers for our Spanish-speaking patients. (Image of Lita) This project is near and dear to my heart because my 93 year old grandmother is an immigrant from Costa Rica who only speaks Spanish and needs additional language assistance for her healthcare needs. (Images of Hispanic women) Did you know that the Hispanic population of Utah increased by almost 40% since 2010 and is expected to increase by another 40% by 2030? Hispanics in Utah County make up 14% of the population and more than a third don’t speak English very well. (Image of word cloud) Hispanics living in Utah experience many health disparities that result in significantly increased risks for illness, chronic disease, and poor maternal/infant outcomes. Language barriers exacerbate these risks and result in poor quality of care and outcomes for these already vulnerable patients. The good news is current evidence shows that specific interventions to overcome language barriers improve these health outcomes, patient satisfaction, and health literacy. (Images CLAS standards, language barriers, 3 interventions) There are national standards and legal requirements for caring for patients with limited English proficiency. We are required to provide the same quality care for ALL patients, regardless of which language they speak. Providing 1) language-concordant care with bilingual staff and providers, 2) professional medical interpreters, and 3) written resources that are language-appropriate ensures we provide high-quality care to patients that speak other languages. (Image Valley policy) Valley has a policy that fulfills the legal requirements and national standards for language services and it must be followed by all staff and providers. The main points of the policy will be covered in this video. (Image of Workflow) We’ve developed a workflow that streamlines our clinic processes for interactions with Spanish-speaking patients. It indicates what should be done, who should do it, and what should be documented. This workflow has been attached as a file with this video link so check it out to see your specific responsibilities based on your role with Valley. I’m going to review a few important points that should help everyone know what to do. (Image of front desk staff, new flags) When a patient calls to schedule an appointment that the receptionist suspects might speak another language, they will ask about the patient’s preferred language. If the patient prefers Spanish, the receptionist will then ask if the patient would like to use professional medical interpretation or work with Spanish-speaking staff and providers. The receptionist will add the flag “No English” for all patients that require a professional medical interpreter, this includes patients that speak languages other than Spanish. Or they’ll add the Speech flag if the patient prefers to work with Spanish-speaking providers. The receptionist will route the call to a Spanish-speaking receptionist if available or connect to a phone interpreter to finish the phone call. They will also be adding extra time to visits that will require interpretation. (Image of nurse on phone) The flag in the chart will alert triage nurses to the patient’s preferences for language interpretation. Depending on the patient’s preference, the nurse will route the call to a Spanish-speaking nurse if available or connect to a phone interpreter to finish the phone call. Nurses should not delay responding to calls if a bilingual nurse is not available. 48 They should also clearly document whether or not an interpreter was refused or used, and record the reference number for any interpretation use in their triage note. (Image of receptionist on phone) Let’s talk about clinic visits! Our Spanish-speaking receptionists will have a plaque that says “Se Habla Español” in front of their station that will make it easier for Spanish-speaking patients to check in and out. If no Spanishspeaking receptionists are available, the receptionist will connect to an interpreter with the iPad. The receptionists will be responsible for having patients sign this form that indicates their preference for interpretation or working with Spanish-speaking staff and providers and gives them the opportunity to officially refuse interpretation if that is their preference. (Images Ultrasound, lab, MA, Providers) In the back office, all medical assistants, ultrasound technicians, lab technicians, and providers should be using the interpreter for each encounter they have with a patient that does not speak English, unless the patient has signed a refusal form. Everyone should also be using language-appropriate written resources. (Image of folder on Vdrive, Spanish forms and handouts) All of our most frequently used written materials have been professionally translated into Spanish. We have made this folder on the VDrive that is called Spanish Forms and handouts. It has intake forms, history and physical forms, mental health screeners, patient education handouts, as well as the policy and workflow information. This is an awesome resource for our Spanish-speaking patients so check it out! (Video and images Sign into app, back of app) You’ll need to do a couple of things to prepare for encounters that require interpretation. Check the iPad to ensure it is working and that the sign-in information is already in the app. If its not signed in, the username and password can be found on the back of the iPad. If you have problems with the iPad, you can troubleshoot with the help of another medical assistant or contact one of the managers. If the iPad cannot be set up, there is a phone interpreter service that is also easy to use. (Image of Vdrive and how to use translator document) The phone number for the video interpreter can be found on the V drive under Spanish forms and handouts (Video of starting the app) Starting the app is super is easy. Turn the iPad on. Push the home screen. Enter the code which is 9635. Tap on the interpretation app. Select the language needed. And then wait for a few seconds while you’re connect to an interpreter. And that’s it! (Video how to use an interpreter) Here are just a few quick tips about using an interpreter: Make sure to introduce yourself and give a brief overview of the purpose of the communication needed. Speak directly to the patient, not the interpreter. Maintain eye- contact with the patient and try to establish a rapport with them, just as you would with an English-speaking patient. Speak in the first person. Avoid slang and complex terminology whenever possible. Be aware that your cultural norms might be different than those of your patients. (Image of notes-Where to document) Documentation of how a visit is conducted is very important. If an interpreter is used, they will always provide you with their name and a reference number. Document it in the text box in the prenatal flowsheet or in the HPI section of progress or annual note. If the visit was conducted by a bilingual provider, that should be documented as well. (Image of medical assistant) Bilingual staff who are not assigned to a patient’s care cannot interpret for another person unless they have passed a certification exam. Since Valley hasn’t paid for any of our bilingual staff to be certified, you shouldn’t be asking them to come in and translate an entire visit for you. But if they’re helping with simple instructions like where to check out and how to get a urine sample, that’s less of a concern. 49 (Slide with info on providing direct care) However, bilingual staff and providers may provide direct care for patients they are assigned to, within their scope of responsibility. (Images or videos of Hispanic women) We have an ethical and legal obligation to provide the same high-quality care that we do for English-speaking patients as we do for Spanish-speaking patients and patients that speak ALL languages. Hopefully, this video has taught you simple things you can do to that will result in significant improvement for our patients and will help us feel proud of the services we’re providing. (Image of Muchas Gracias) Thank you so much for watching! Please let me know if you have any questions. You received a link to a survey with this video file. It takes less than 5 minutes to complete, so please fill it out now! Thanks everyone! 50 Appendix E Pre-Implementation Survey Staff and Provider Survey: Addressing Language Barriers for Spanish-speaking Patients Thank you for completing this survey! It will take you around 5 minutes to complete. The information from this survey will help us improve the language services we provide to our Spanish-speaking patients here at Valley Women's Health. This survey is also part of a scholarly quality improvement project for a Doctor of Nursing Practice program at the University of Utah. If you have questions about the survey, contact Erica Nelson CNM at XXX-XXX-XXXX. Thank you! The first 5 questions will help us collect demographic data. However, none of the questions will specifically identify you and your responses will remain anonymous. 1. What is your Job Title at Valley Women's Health? Front office staff Medical assistant/CNA Lab technician Ultrasound technician Registered Nurse Certified Nurse-Midwife Nurse Practitioner Physician 2. How many years have you been employed with Valley Women's Health? Less than one year 1-5 years 6-10 years 10+ years 3. What is your age? 18-24 25-34 35-44 45-54 55-64 65+ 4. What is your ethnicity? Hispanic or Latino(a) Non-Hispanic 5. What is your race? Choose all that apply. White Black or African Native American or Alaska Native Asian Native Hawaiian or other Pacific Islander The next question will help us learn about your ability to communicate in Spanish. 6. Choose the response that best describes your ability to communicate with Spanish-speaking patients. I don't know any Spanish at all I can understand and/or speak a little Spanish I can understand and/or speak in Spanish most of the time I can communicate comfortably with Spanish-speaking patients without the help of an interpreter, patient's family member, or staff member 51 "Professional medical interpretation" refers to the medical language interpreters that are accessed via our iPads. The following 7 questions are about using professional medical interpretation. 7. I am satisfied with the professional medical interpretation services that are available via the iPads. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 8. I can identify which patients need professional medical interpretation by looking at their charts on Greenway. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 9. I know where to document the use of professional medical interpretation for encounters with Spanish-speaking patients. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 10. Patients who prefer to speak Spanish get better care when professional medical interpretation is used. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 11. It is easy to use the iPads for professional medical interpretation. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 12. Using staff members to interpret for me is more effective than the professional medical interpretation on the iPad. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 13. I can deliver high quality care using a family member to translate instead of professional medical interpretation. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree The next 3 questions are about written forms and handouts that have been translated into Spanish. 14. I am satisfied with the Spanish patient forms and handouts I currently have access to. Strongly disagree Disagree Neither agree nor disagree Agree 52 Strongly agree 15. I know where to find patient information or handouts in Spanish that I can provide to my patients. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 16. I feel that having patient handouts in Spanish helps me provide high-quality care for my Spanish-speaking patients. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree The last 4 questions assess what you learned in the attached video, allow you to give feedback on the new protocols, and give you an opportunity to share your ideas for improving our language services to Spanishspeaking patients. 17. I feel confident in my understanding of the interpretation services policy at Valley Women's Health. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 18. The video helped me to understand my role in using interpretation services appropriately. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 19. The information in the video will make it easier for me to provide high-quality care for my Spanish-speaking patients. Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 20. Please use the box to write any other ideas for improving the language services we provide to Spanish-speaking patients. 53 Appendix F Plan, Do, Study, Act Cycles Problem Lab technicians are not using language interpretation for Spanishspeaking patients. They are asking bilingual staff to interpret brief, repetitive instructions. Objective Develop Spanish instruction cards with frequently used instructions. Plan Lead lab technician collaborated with other technicians to determine which instructions/information to put on cards Do DNP student created lab instruction cards. Correct translation was verified by a native speaker and Google Translate. The cards were taken to each clinic site. Lead lab technician informed other technicians of location of cards and how to use them appropriately. Study Lead lab technician reported feedback at one week and two weeks after use. This information was reported to Lab Manager who did not have additional recommendations. Act Decision was made to continue to use the cards. Problem One triage nurse is responding to many Spanish-speaking patients' calls, medication refills, and lab follow-ups. This triage nurse is accruing overtime. Objective Develop a system to reduce overtime while ensuring Spanish-speaking patients have a bilingual nurse to follow-up on their care. Plan Clinical manager tracked number of Spanish-speaking calls and followup. Discussed concerns with Spanish-speaking RN, Clinical Director, and DNP student. Do Clinical manager created a team of two bilingual RNs to respond to triage issues for Spanish-speaking patients. She created a chat group for other nurses and providers to send the Spanish team items needing follow-up. She informed nurses and providers via AzovaTM message of the new system. Study DNP student interviewed bilingual RN on Spanish triage team at one month after team creation. The RN reports no overtime, the team is effectively responding to all calls and message for follow-up that they 54 are sent. The number of calls/tasks ranges from one to eight per nurse per day. Act Decision was made to continue use of the Spanish team. Problem Weekly rounding revealed that very few staff/providers knew where to find the newly translated Spanish forms and handouts. Objective Develop reminders with file location of Spanish forms and handouts Plan DNP student discussed issue with clinical manager, lead medical assistant, and other medical assistants. Reminder cards were developed for each job description that included part of the clinical workflow and the file location. Do The cards were placed on desktop computers for staff and providers. Study DNP student interviewed staff and providers at one week after placing cards to determine if the cards helped them find Spanish forms and handouts. Physicians and staff were satisfied with the cards with the file location. They requested they be kept for continued use but recommended the cards be moved from the computer displays to their drawers Act Cards were laminated and placed in a permanent location inside provider and staff drawers for easy access. 55 Appendix G Post-Implementation Survey Post-Survey: Improving Language Services for Spanish-speaking Patients Thank you for completing this survey! It will take you less than 5 minutes to complete. The information from this survey will help us evaluate the project to improve Valley's language services for Spanish-speaking patients. Links to the resources and training documents are included below if you need to take a look at them again! PDF How to find Spanish forms.pdf PDF Clinic Workflow for Language Services.pdf Language Services Training Video If you have questions about the survey, please contact Erica Nelson CNM at 801-376-1109. Thank you! The first 5 questions will help us collect demographic data. However, none of the questions will specifically identify you and your responses will remain anonymous. 1. What is your Job Title at Valley Women's Health? Front office staff Medical assistant/CNA Lab technician Ultrasound technician Registered Nurse Certified Nurse-Midwife Nurse Practitioner Physician 2. How many years have you been employed with Valley Women's Health? Less than one year 1-5 years 6-10 years 10+ years 3. What is your age? 18-24 25-34 35-44 45-54 55-64 65+ 4. What is your ethnicity? Hispanic or Latino(a) Non-Hispanic 5. What is your race? Choose all that apply. White Black or African Native American or Alaska Native Asian Native Hawaiian or other Pacific Islander 6. Did you complete the first survey that was sent out about this project that accompanied the training video? Yes No I don’t remember The following 6 questions address the iPad/phone service for professional language interpretation. 56 7. Do you use the iPad/phone system for professional language interpretation when communicating with Spanishspeaking patients? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 8. If so, how often? Never Rarely Occasionally Frequently Always 9. Can you identify which patients need professional language interpretation by looking at their charts on Greenway? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 10. If you use the iPad/phone system for professional language interpretation, do you know where to document it? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 11. If a patient refuses professional language interpretation, do you use the new refusal form created by Valley's quality committee? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 12. Are you satisfied with the iPad/phone system professional language interpretation services? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree The following 4 questions address patient forms and handouts (like consent forms, intake forms, patient education handouts) that are available in Spanish. 13. Do you use Spanish patient forms and handouts for Spanish-speaking patients? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 14. If so, how often do you use them for Spanish-speaking patients? Never Rarely Occasionally Frequently Always 15. Do you know where to find Spanish patient forms and handouts? 57 Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 16. Are you satisfied with the Spanish patient forms and handouts that are available? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree The last 3 questions evaluate this project to address language barriers for Spanish-speaking patients. 17. Which of the following interventions from this project helped you know how to provide appropriate services to Spanish-speaking patients? (Select all that apply) Language services training video Clinic workflow document Reminder cards on computer stations Erica’s drop-in visits Reminder texts from your manager Word-of-mouth from other staff/providers 18. Do you think this project’s interventions have improved language services for Spanish-speaking patients? Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 19. Please use the box to write any other ideas for improving the language services we provide to Spanish-speaking patients. 58 Appendix H Spanish Instruction Cards for Lab Draws 59 Appendix I Executive Summary