Improving Equity of Care for Patients with Limited English Proficiency Using Quality Improvement Methodology

Abstract

Disparate clinical outcomes have been reported for patients with Limited English Proficiency (LEP) in the emergency department setting, including increased length of stay, diagnostic error rates, readmission rates, and dissatisfaction. Our emergency department had no standard processes for LEP patient identification or interpreter encounter documentation and a higher rate of 48-hour LEP return visits (RV) than English proficient patients. The aim was to eliminate gaps by increasing appropriate interpreter use and documentation (AIUD) for Spanish-speaking LEP (LEP-SS) patients from 35.7% baseline (10/17-05/18) to 100% by October 2020.

Methods: LEP-SS patient data were reviewed in the electronic medical record to determine the AIUD and RV rates. Using the Model for Improvement and multiple Plan-Do-Study-Act (PDSA) cycles, a multi-disciplinary team encouraged stakeholder engagement and identified improvement opportunities, implemented an electronic tracking board LEP icon (PDSA1), standardized documentation using an LEP Form linked to the icon (PDSA2), and included color changes to the icon for team situational awareness (PDSA3).

Results: The mean of LEP-SS patients with AIUD improved from 35.7% to 64.5% without significant changes in balancing measures. During the postintervention period (6/1/2018-10/31/2020), no special cause variation was noted from the baseline 48-hour emergency department RV rates for LEP patients (3.1%) or English proficient patients (2.6%).

Conclusions: While the RV rate was not affected, this project is part of a multi-faceted approach aiming to positively impact this outcome measure. Significant improvements in AIUD were achieved without affecting balancing measures.

Fig. 1.

Key driver diagram showing the project aim, and the primary and secondary drivers that contribute toward achieving the aim.

Fig. 2.

Percent of LEP-SS patients who had an interpreter used and documented in the ED. LEP-SS patients who refused or did not need an interpreter were not included. Process measure tests are performed with unequal sample sizes.

Fig. 3.

ED LEP-SS patients who had the LEP icon activated for identification and awareness along with AIUD. The red squares at Feb-19 and Jul-20 indicate special cause points outside control limits. LEP-SS patients who refused or did not need an interpreter were not included. Process measure tests are performed with unequal sample sizes.

Fig. 4.

Percent of LEP-SS patients who had an interpreter used and documented in the UCC location with the most baseline LEP visits.

Fig. 5.

Percent of LEP ED and EP ED patients who returned to the ED within 48 hour of initial visit. A, B, Percent of LEP ED and EP ED patients who returned to the ED within 48 hours of initial visit. The red squares at Aug-18 and Aug-20 indicate special cause points outside control limits. Outcome measure tests are performed with unequal sample sizes.