Language services in hospitals: discordance in availability and staff use.

Despite efforts to advance effective patient-provider communication, many patients' language needs continue to be unmet or inappropriately addressed by healthcare providers (Wielawski 2010; Patek et al. 2009; Wilson-Stronks and Galvez 2007). This study presents a picture of the language resources currently provided by hospitals and those resources practitioners actually use. Questionnaire data were collected from 14 hospitals in Florida's Palm Beach, St. Lucie, and Martin counties on availability, staff awareness, and staff use of linguistic resources and services. Inconsistencies were identified between the language tools, services, and resources hospitals provide and those staff use. In addition, a large majority of staff respondents still rely upon someone accompanying the patient for communication with patients who have limited English proficiency, despite evidence that this practice contributes to miscommunication and serious medical errors (Flores et al. 2003; Flores 2005; HHS OMH 2001; Patek et al. 2009). Hospitals that use bilingual staff as interpreters often do not test the competency of these staff, nor do they assess the utilization or effectiveness of the tools and resources they provide. Hospitals can improve the cultural and linguistic care they provide if they (1) address the practice of using ad hoc interpreters, (2) effectively disseminate information to hospital staff regarding how and when to access available resources, and (3) collect patient population data and use it to plan for and evaluate the language services they provide to their patients.

The perceived impact of public reporting hospital performance data: interviews with hospital staff.

OBJECTIVE: To assess perceptions about the value and impact of publicly reporting hospital performance measure data. DESIGN: Qualitative research. SETTING AND PARTICIPANTS: Administrators, physicians, nurses and other front-line staff from 29 randomly selected Joint Commission-accredited hospitals reporting core performance measure data. METHODS: Structured focus-group interviews were conducted to gather hospital staff perceptions of the perceived impact of publicly reporting performance measure data. RESULTS: Interviews revealed six common themes. Publicly reporting data: (i) led to increased involvement of leadership in performance improvement; (ii) created a sense of accountability to both internal and external customers; (iii) contributed to a heightened awareness of performance measure data throughout the hospital; (iv) influenced or re-focused organizational priorities; (v) raised concerns about data quality and (vi) led to questions about consumer understanding of performance reports. Few differences were noted in responses based on hospitals' performance on the measures. CONCLUSIONS: Public reporting of performance measure data appears to motivate and energize organizations to improve or maintain high levels of performance. Despite commonly cited concerns over the limitations, validity and interpretability of publicly reported data, the heightened awareness of the data intensified the focus on performance improvement activities. As the healthcare industry has moved toward greater transparency and accountability, healthcare professionals have responded by re-prioritizing hospital quality improvement efforts to address newly exposed gaps in care.

Towards an International Classification for Patient Safety: the conceptual framework.

Global advances in patient safety have been hampered by the lack of a uniform classification of patient safety concepts. This is a significant barrier to developing strategies to reduce risk, performing evidence-based research and evaluating existing healthcare policies relevant to patient safety. Since 2005, the World Health Organization's World Alliance for Patient Safety has undertaken the Project to Develop an International Classification for Patient Safety (ICPS) to devise a classification which transforms patient safety information collected from disparate systems into a common format to facilitate aggregation, analysis and learning across disciplines, borders and time. A drafting group, comprised of experts from the fields of patient safety, classification theory, health informatics, consumer/patient advocacy, law and medicine, identified and defined key patient safety concepts and developed an internationally agreed conceptual framework for the ICPS based upon existing patient safety classifications. The conceptual framework was iteratively improved through technical expert meetings and a two-stage web-based modified Delphi survey of over 250 international experts. This work culminated in a conceptual framework consisting of ten high level classes: incident type, patient outcomes, patient characteristics, incident characteristics, contributing factors/hazards, organizational outcomes, detection, mitigating factors, ameliorating actions and actions taken to reduce risk. While the framework for the ICPS is in place, several challenges remain. Concepts need to be defined, guidance for using the classification needs to be provided, and further real-world testing needs to occur to progressively refine the ICPS to ensure it is fit for purpose.

Case volume and hospital compliance with evidence-based processes of care.

BACKGROUND: For many complex cardiovascular procedures the well-established link between volume and outcome has rested on the underlying assumption that experience leads to more reliable implementation of the processes of care which have been associated with better clinical outcomes. This study tested that assumption by examining the relationship between cardiovascular case volumes and the implementation of twelve basic evidence-based processes of cardiovascular care. METHOD AND RESULTS: Observational analysis of over 3000 US hospitals submitting cardiovascular performance indicator data to The Joint Commission on during 2005. Hospitals were grouped together based upon their annual case volumes and indicator rates were calculated for twelve standardized indicators of evidence-based processes of cardiovascular care (eight of which assessed evidenced-based processes for patients with acute myocardial infarction and four of which evaluated evidenced-based processes for heart failure patients). As case volume increased so did indicator rates, up to a statistical cut-point that was unique to each indicator (ranging from 12 to 287 annual cases). t-Test analyses and generalized linear mixed effects logistic regression were used to compare the performance of hospitals with case volumes above or below the statistical cut-point. Hospitals with case volumes that were above the cut-point had indicator rates that were, on an average, 10 percentage points higher than hospitals with case volumes below the cut-point (P < 0.05). CONCLUSION: Hospitals treating fewer cardiovascular cases were significantly less likely to apply evidence-based processes of care than hospitals with larger case volumes, but only up to a statistically identifiable cut-point unique to each indicator.

Language proficiency and adverse events in US hospitals: a pilot study.

OBJECTIVE: To examine differences in the characteristics of adverse events between English speaking patients and patients with limited English proficiency in US hospitals. SETTING: Six Joint Commission accredited hospitals in the USA. METHOD: Adverse event data on English speaking patients and patients with limited English proficiency were collected from six hospitals over 7 months in 2005 and classified using the National Quality Forum endorsed Patient Safety Event Taxonomy. RESULTS: About 49.1% of limited English proficient patient adverse events involved some physical harm whereas only 29.5% of adverse events for patients who speak English resulted in physical harm. Of those adverse events resulting in physical harm, 46.8% of the limited English proficient patient adverse events had a level of harm ranging from moderate temporary harm to death, compared with 24.4% of English speaking patient adverse events. The adverse events that occurred to limited English proficient patients were also more likely to be the result of communication errors (52.4%) than adverse events for English speaking patients (35.9%). CONCLUSIONS: Language barriers appear to increase the risks to patient safety. It is important for patients with language barriers to have ready access to competent language services. Providers need to collect reliable language data at the patient point of entry and document the language services provided during the patient-provider encounter.

Performance of top-ranked heart care hospitals on evidence-based process measures.

BACKGROUND: Despite the increasing availability of evidence-based clinical performance measure data that compares the performances of US hospitals, the general public continues to rely on more popular resources such as the US News & World Report annual publication of "America's Best Hospitals" for information on hospital quality. This study evaluated how well hospitals ranked on the US News & World Report list of top heart and heart surgery hospitals performed on acute myocardial infarction and heart failure measures derived from American College of Cardiology and American Heart Association clinical treatment guidelines. METHODS AND RESULTS: This study identified 774 hospitals, including 41 of the US News & World Report top 50 heart and heart surgery hospitals. To compare hospitals, 10 rate-based performance measures (6 addressing processes of acute myocardial infarction care and 4 addressing heart failure care), were aggregated into a cardiovascular composite measure. As a group, the US News & World Report hospitals performed statistically better than their peers (mean, 86% versus 83%; P < 0.05). Individually, however, only 23 of the US News & World Report hospitals achieved statistically better-than-average performance compared with the population average, whereas 9 performed significantly worse (P < 0.05). One hundred sixty-seven hospitals in this study routinely implemented evidenced-based heart care > or = 90% of the time. CONCLUSIONS: A number of the US News & World Report top hospitals fell short in regularly applying evidenced-based care for their heart patients. At the same time, many lesser known hospitals routinely provided cardiovascular care that was consistent with nationally established guidelines.

Assessing the reliability of standardized performance indicators.

OBJECTIVE: . To investigate the reliability of self-reported standardized performance indicators introduced by the Joint Commission on Accreditation of Healthcare Organizations in July 2002 and implemented in approximately 3400 accredited US hospitals. The study sought to identify the most common data quality problems and determine causes and possible strategies for resolution. DESIGN: Data were independently reabstracted from a random sample of 30 hospitals. Reabstracted data were compared with data originally abstracted, and discrepancies were adjudicated with hospital staff. Structured interviews were used to probe possible reasons for abstraction discrepancies. RESULTS: The mean data element agreement rate for the 61 data elements evaluated was 91.9%, and the mean kappa statistic for binary data elements was 0.68. The rate of agreement for individual data elements ranged from 100 to 62.4%. The mean difference between calculated indicator rates was 4.88% (absolute value) and the range of differences was 0.0-13.3%. Symmetry of disagreement among original abstractors and reabstractors identified eight indicators whose differences in calculated rates were statistically unlikely to have occurred through random chance (P < 0.05). CONCLUSION: Although improvement in the accuracy and completeness of the self-reported data is possible and desirable, the baseline level of data reliability appears to be acceptable for indicators used to assess and improve hospital performance on selected clinical topics.

Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004.

BACKGROUND: In July 2002, the Joint Commission on Accreditation of Healthcare Organizations implemented standardized performance measures that were designed to track the performance of accredited hospitals and encourage improvement in the quality of health care. METHODS: We examined hospitals' performance on 18 standardized indicators of the quality of care for acute myocardial infarction, heart failure, and pneumonia. One measure assessed a clinical outcome (death in the hospital after acute myocardial infarction), and the other 17 measures assessed processes of care. Data were collected over a two-year period in more than 3000 accredited hospitals. All participating hospitals received quarterly feedback in the form of comparative reports throughout the study. RESULTS: Descriptive analysis revealed a significant improvement (P<0.01) in the performance of U.S. hospitals on 15 of 18 measures, and no measure showed a significant deterioration. The magnitude of improvement ranged from 3 percent to 33 percent during the eight quarters studied. For 16 of the 17 process-of-care measures, hospitals with a low level of performance at baseline had greater improvements over the subsequent two years than hospitals with a high level of performance at baseline. CONCLUSIONS: Over a two-year period, we observed consistent improvement in measures reflecting the process of care for acute myocardial infarction, heart failure, and pneumonia. Both quantitative and qualitative research are needed to explore the reasons for these improvements.