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. 2022 Aug 1;176(8):776-786.
doi: 10.1001/jamapediatrics.2022.1831.

Association of Patient and Family Reports of Hospital Safety Climate With Language Proficiency in the US

Alisa Khan  1   2 , Victoria Parente  3 , Jennifer D Baird  4 , Shilpa J Patel  5   6 , Sharon Cray  7   8 , Dionne A Graham  2   9 , Monique Halley  8 , Tyler Johnson  1 , Erin Knoebel  10 , Kheyandra D Lewis  7   11 , Isabella Liss  1 , Eileen M Romano  12 , Shrunjal Trivedi  9 , Nancy D Spector  11   13 , Christopher P Landrigan  1   2   14 ; Patient and Family Centered I-PASS SCORE Scientific Oversight Committee; Ellen J Bass  15   16 , Sharon Calaman  17   18 , April E Fegley  19 , Andrew J Knighton  20 , Jennifer K O'Toole  21   22   23 , Theodore C Sectish  1   2 , Rajendu Srivastava  20   24   25 , Amy J Starmer  1   2 , Daniel C West  26   27
Affiliations

Association of Patient and Family Reports of Hospital Safety Climate With Language Proficiency in the US

Alisa Khan et al. JAMA Pediatr. .

Abstract

Importance: Patients with language barriers have a higher risk of experiencing hospital safety events. This study hypothesized that language barriers would be associated with poorer perceptions of hospital safety climate relating to communication openness.

Objective: To examine disparities in reported hospital safety climate by language proficiency in a cohort of hospitalized children and their families.

Design, setting, and participants: This cohort study conducted from April 29, 2019, through March 1, 2020, included pediatric patients and parents or caregivers of hospitalized children at general and subspecialty units at 21 US hospitals. Randomly selected Arabic-, Chinese-, English-, and Spanish-speaking hospitalized patients and families were approached before hospital discharge and were included in the analysis if they provided both language proficiency and health literacy data. Participants self-rated language proficiency via surveys. Limited English proficiency was defined as an answer of anything other than "very well" to the question "how well do you speak English?"

Main outcomes and measures: Primary outcomes were top-box (top most; eg, strongly agree) 5-point Likert scale ratings for 3 Children's Hospital Safety Climate Questionnaire communication openness items: (1) freely speaking up if you see something that may negatively affect care (top-box response: strongly agree), (2) questioning decisions or actions of health care providers (top-box response: strongly agree), and (3) being afraid to ask questions when something does not seem right (top-box response: strongly disagree [reverse-coded item]). Covariates included health literacy and sociodemographic characteristics. Logistic regression was used with generalized estimating equations to control for clustering by site to model associations between openness items and language proficiency, adjusting for health literacy and sociodemographic characteristics.

Results: Of 813 patients, parents, and caregivers who were approached to participate in the study, 608 completed surveys (74.8% response rate). A total of 87.7% (533 of 608) of participants (434 [82.0%] female individuals) completed language proficiency and health literacy items and were included in the analyses; of these, 14.1% (75) had limited English proficiency. Participants with limited English proficiency had lower odds of freely speaking up if they see something that may negatively affect care (adjusted odds ratio [aOR], 0.26; 95% CI, 0.15-0.43), questioning decisions or actions of health care providers (aOR, 0.19; 95% CI, 0.09-0.41), and being unafraid to ask questions when something does not seem right (aOR, 0.44; 95% CI, 0.27-0.71). Individuals with limited health literacy (aOR, 0.66; 95% CI, 0.48-0.91) and a lower level of educational attainment (aOR, 0.59; 95% CI, 0.36-0.95) were also less likely to question decisions or actions.

Conclusions and relevance: This cohort study found that limited English proficiency was associated with lower odds of speaking up, questioning decisions or actions of providers, and being unafraid to ask questions when something does not seem right. This disparity may contribute to higher hospital safety risk for patients with limited English proficiency. Dedicated efforts to improve communication with patients and families with limited English proficiency are necessary to improve hospital safety and reduce disparities.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Khan reported receiving grants from the Patient-Centered Outcomes Research Institute (PCORI) and the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study and receiving honoraria from AHRQ outside the submitted work. Dr Parente reported receiving grants from the National Institutes of Health (NIH) outside the submitted work. Dr Baird reported receiving grants from PCORI during the conduct of the study and consulting fees from the I-PASS Patient Safety Institute outside the submitted work. Dr Patel reported receiving grants from PCORI during the conduct of the study and holding equity in and serving as a consultant for the I-PASS Patient Safety Institute. Ms Johnson reported receiving grants from PCORI during the conduct of the study. Dr Spector reported receiving grants from PCORI during the conduct of the study; holding equity in and receiving consulting fees from the I-PASS Patient Safety Institute outside the submitted work; and receiving monetary award, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on physician performance and handoffs. Dr Landrigan reported receiving grants from PCORI during the conduct of the study; receiving personal fees from the I-PASS Patient Safety Institute and Missouri Hospital Association/Executive Speakers’ Bureau outside the submitted work; receiving monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety; holding equity in and serving as a consultant for the I-PASS Patient Safety Institute; and serving as an expert witness in cases regarding patient safety and sleep deprivation. Dr Calaman reported receiving grants from PCORI during the conduct of the study and holding stock options and serving as a consultant for the I-PASS Patient Safety Institute. Dr Knighton reported receiving grants from PCORI during the conduct of the study, the Moor Foundation, and the NIH outside the submitted work; owning publicly traded stock in UnitedHealth Group; and receiving personal fees from the American College of Chest Physicians outside the submitted work. Dr O’Toole reported receiving grants from PCORI during the conduct of the study; receiving personal fees from the I-PASS Patient Safety Institute outside the submitted work; and holding stock options in and serving as a consultant for the I-PASS Patient Safety Institute. Dr Sectish reported serving as a consultant for and receiving equity interest in the I-PASS Patient Safety Institute outside the submitted work and eceiving monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on physician performance and handoffs. Dr Srivastava reported being a physician founder of the I-PASS Patient Safety Institute, with his equity owned by his employer, Intermountain Healthcare, during the conduct of the study; receiving grants from PCORI, NIH, AHRQ, and Centers for Disease Control and Prevention paid to his institution outside the submitted work; and receiving monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching about pediatric hospitalist research networks and quality of care. Dr Starmer reported receiving grants from PCORI during the conduct of the study; holding equity in, serving as a consultant for, and receiving personal fees from the I-PASS Patient Safety Institute outside the submitted work; and receiving monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on handoffs and patient safety. Dr West reported receiving grants from PCORI during the conduct of the study; being a cofounder of, consultant for, and holding equity in the I-PASS Patient Safety Institute; and receiving monetary awards, honoraria, and travel reimbursements from multiple academic, regulatory, and professional organizations for teaching and consulting on handoff safety and competency-based medical education. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Top-Box Patient- or Family-Reported Hospital Safety Climate Items by Language Proficiency
The bottom statement is a negatively worded question that was reverse coded. EP indicates English proficiency. LEP, limited English proficiency. aP <.001.
Figure 2.
Figure 2.. Top-Box Patient- or Family-Reported Hospital Safety Climate Items by Health Literacy
The bottom statement is a negatively worded question that was reverse coded. aP <.05.
See this image and copyright information in PMC

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