Form #3 Form #3 Master-Training Guide

TM

Enhancing Safety for Patients with
Limited English Proficiency
Train-the-Trainer Instructor Guide

LEP

Pre-Work
Send pre-work materials to training participants at least two
weeks before the training.

Dear TeamSTEPPS trainers,

PREWORK
TIME:
30 minutes

We look forward to seeing you soon for the TeamSTEPPS
training to improve the safety of patients with limited English
Proficiency (LEP).

Slide

A while back, you completed a readiness assessment survey
to check whether your institution was ready for this training.
Now, we ask that you complete a brief site assessment to
help us have a productive training.
The site assessment includes completing a site assessment
questionnaire, completing a language process map, and
making a copy of your hospital’s or organization’s policy on
accessing language services to bring to the training. We
estimate these tasks may take approximately 30 minutes.
Please do not hesitate to let us know if you have any
questions.

Best regards,

[Trainer names, signature and contact information]

TeamSTEPPS | Limited English Proficiency

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Pre-Work: Site Assessment for Trainers
Please take a moment to answer the questions below. This will
help you to customize the training module to your audience’s
needs.

1.

What percentage of your patients have limited English
proficiency?

2.

What are the most common languages spoken by your
patients?

Slide

3.

How do staff in your clinical area…
a. Identify patient language needs
b. Contact an interpreter
c. Ensure that the interpreter is present for the entire
encounter
d. Ensure that the interpreter is fully informed and integrated
into the team?
To answer these questions, please complete the attached
Patient Language Process Map, with information for your
unit, and mark the areas of risk or areas needing
improvement

4.

Please attach a copy of your hospital or organization’s
policies for calling an interpreter.
What are your contingency plans: what happens when the
interpreter is unavailable, late, or cannot stay for the entire
patient encounter?

5.

2

List some examples of real situations from your
hospital/clinical area in which LEP patients were at risk due
to language barriers and/or not having an interpreter
available (use the reverse side of this sheet if needed).

TeamSTEPPS 10.10 | Limited English Proficiency

LEP

Slide

TeamSTEPPS | Limited English Proficiency

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Train-the-Trainer Session Agenda

TRAIN-THETRAINERS

• Experience the pre-training evaluation questionnaires as
intended for students (15 mn)

SESSION
TIME:

• Experience the module as intended for students (60 mn)

4.5Slide
hours

• Experience the post-training evaluation questionnaires as
intended for students (15 mn)

~ Break – 10 minutes ~

• Debrief on teaching points and areas for customization (15
mn)
MATERIALS:
• Training Module
slides

• Review pre-work assignments (35 minutes)
• Conduct Implementation planning (45 minutes)

• Videos
• Module Exercise
worksheets
• Pens

• Practice teaching parts of the module (40 minutes)

• Implementation
slides

• Wrap-up and Q&A and evaluation (15 minutes)

• Evaluation Guide
• Implementation
worksheets
• Process maps
prepared in prework
• Blank process
maps
• Policies identified
in pre-work
• Evaluation forms

4

~ Lunch – 20 minutes ~

LEARNING OBJECTIVES:
1. Understand the evidence on patient safety risks to LEP
patients
2. Assemble the most appropriate and effective care team for
LEP patients
3. Identify and raise patient communication issues
4. Use the site readiness assessment to customize training and
implementation plans
5. Develop an implementation plan
6. Develop the ability to teach Objectives 1 – 3

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INTRODUCTION
SAY:
We begin this Train-the-Trainer session with the module itself,
just as you will present it to your participants. Please locate and
use your slide handouts for the module “Enhancing Safety for
Patients with Limited English Proficiency” and follow along, noting
areas where you may wish to customize the material for your own
group. The “script” of notes for these slides will be provided to
you later in this session.
In recent years, the Agency for Healthcare Research and Quality
and the Department of Defense have worked together to enhance
patient safety. The TeamSTEPPS system is a powerful set of
teachable and trainable skills, behaviors and tools that has been
shown to reduce medical errors. In this module, we show how the
TeamSTEPPS system can be used to enhance the safety of
patients with Limited English Proficiency (LEP).
Before we start the module, I’d like you to complete a baseline
survey. This survey is anonymous and will help us track our
progress as a team. Everyone in this session should complete
the learning outcomes survey. In addition, everyone in the group
except for interpreters should complete the baseline behavior
change survey. You will have 10 minutes to complete these
surveys.

Slide

MODULE
TIME:
60 minutes

EVALUATION:
15 minutes pretraining
15 minutes
post-training

(Collect baseline surveys and thank participants).
INSTRUCTOR NOTE:

MATERIALS:

This module may be customized based on the group’s knowledge
and experience with LEP and culturally diverse patients and
TeamSTEPPSTM. For example, if the group is aware of medically
significant miscommunication incidents that have occurred with
LEP patients in their hospital, it may be useful to replace one of
the presentation’s case examples with the example that
participants know. Similarly, depending on the amount of
exposure to TeamSTEPPS, the group may need more or fewer
slides with information on TeamSTEPPS.

TeamSTEPPS | Limited English Proficiency

• Evaluation forms
• Exercise
worksheets and
pens
• LEP Video
(Opportunity Lost
and Won
examples)

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Overview/Objectives
SAY:
This module will help you to:
 Understand the patient safety risk to patients with limited
English proficiency

Slide

 Know the process to assemble the most appropriate and
effective care team for LEP and culturally diverse patients
 Identify and raise patient communication issues

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LEP

The Story of Willie Ramirez
SAY:
To illustrate why LEP patients are at risk of patient safety events, I
would like to share the story of Willie Ramirez. This case is one of
the most well-known examples in which limited English proficiency
and cultural misunderstandings resulted in a tragic medical error.
In 1980, 18-year-old athlete Willie Ramirez was taken to the ER by
ambulance in a coma, accompanied by his Mom, his sister, his
girlfriend, and his girlfriend’s Mom. The ER physician, who did not
speak Spanish, assumed Willie had a drug overdose because he
had pinpoint pupils and because the girlfriend’s Mom said, in
broken English, “he is intoxicado”. In Cuban Spanish “intoxicado”
means “poisoned”. The family thought he had eaten a bad
hamburger at a new Wendy’s that day.

Slide

When the ER doctor told the family he would treat Willie for drug
overdose, they said to one another, in Spanish, “that’s impossible,
he would never take drugs”. Willie was an all-star baseball player
and was opposed to drugs and drinking. However, the doctor did
not understand what the family was saying. Willie’s intracerebral
hemorrhage kept bleeding for more than two days before a
neurological consult was scheduled. By then, Willie was
quadriplegic. The family sued the hospital, resulting in a $71 million
settlement.
In a later interview, the ER doctor said, “If I had a Mom who said,
“My son would NEVER use drugs,” I may have thought differently.”
However, the family member who was interpreting did not share
this information with the doctor, because cultural differences
complicated the language issue. In some cultures, people never
contradict an authority figure, like a doctor.
Neither the doctor nor the family asked for a professional medical
interpreter because they thought they were communicating
adequately. A professional interpreter could have facilitated mutual
understanding by interpreting the doctor’s and family’s words to
one another, asking questions to make sure they understood
correctly, and speaking up when the family expressed doubts about
the doctor’s diagnosis.
INSTRUCTOR NOTE:
You may read the full story here:
http://healthaffairs.org/blog/2008/11/19/language-culture-andmedical-tragedy-the-case-of-willie-ramirez/

TeamSTEPPS | Limited English Proficiency

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LEP

™

High-Risk Settings and Scenarios
SAY:

High-Risk Settings and Situations
 ED
 OB/GYN
 Surgery
 Transitions in care, including intake and discharge
 Medication reconciliation

Mod 8.4.10 Page 4

Research shows that Patient safety events that affect LEP
patients tend to be more severe and more frequently due to
communication errors compared to English-speaking
patients.

TEAM STEPPS 05.2

Slide

While all patients are at greater risk in acute care settings, LEP
patients may be even more vulnerable in interactions with the
ED, OB/GYN or Surgical settings. In situations where care is
time-sensitive and communication with the patient or their
family is important, such as intake, transitions in care,
discharge, and medication reconciliation, LEP patients may
need additional supports to maintain safety.

INSTRUCTOR NOTE:
The points made above are supported by preliminary research
conducted to develop this training module, and by these
references:
Divi C, Koss RG, Schmaltz SP, Loeb JM. Language
proficiency and adverse events in US hospitals: a pilot study.
Intl J Qual Health Care 2006;18:383-388.
Flores G, Laws MB, Mayo SJ, Zuckerman B, Abreu M,
Medina L, Hardt EJ. Errors in medical interpretation and their
potential clinical consequences in pediatric encounters.
Pediatrics 2003;111:6-14.

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LEP

Added risk for LEP Patients

SAY:
Research also indicates that without a professional interpreter,
medical interpretation errors are more common and significantly
more likely to have potential clinical consequences.
When the care team asks family members or housekeeping staff
to interpret, or when they rely on their own limited foreign
language skills or the patient’s limited English, they place LEP
patients at risk for physical harm.

Slide

In addition, they place the ad hoc interpreter at risk for
psychological harm. Imagine how you would feel if you made an
error in interpretation that caused your family member to become
quadriplegic.
Another risky situation is when the interpreter arrives after the
encounter has already begun, or is called away before the
encounter ends. Ideally, the interpreter should be present for the
whole encounter. However, when this is not possible, the
interpreter should be briefed when they arrive and there should be
a backup plan in case they have to leave.

INSTRUCTOR NOTE:
The points made above are supported by preliminary research
conducted to develop this training module, and by these
references:

Flores G. The impact of medical interpreter services
on the quality of health care: a systematic review. Med Care Res
Rev. 2005; 62(3):255-99.
Flores G, Laws MB, Mayo SJ, Zuckerman B, Abreu
M, Medina L, Hardt EJ. Errors in medical interpretation and their
potential clinical consequences in pediatric encounters. Pediatrics
2003;111:6-14.

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LEP

™

LEP patients
in your clinical area

LEP Patients in your Clinical Area
INSTRUCTOR NOTE:
The bullet-points in this slide should be replaced with information
about LEP patients in the clinical area where you are conducting
the training.

 Percentage of patients LEP
 Common languages spoken
 Less common languages
 Specific issues or problems

Interpreter at work…
Mod 8.4.10 Page 6

TEAM STEPPS 05.2

Slide

About the penguins: Graphic design used throughout
TeamSTEPPS, including the cartoon penguins, is inspired by the
2006 book by John Kotter, “Our Iceberg is Melting: Changing and
Succeeding Under Adverse Conditions”. The book illustrates
Kotter’s Eight Stages of Change, a proposed set of steps to
initiate and sustain change in an organization, through the story of
a penguin colony faced with a melting iceberg.

Reference:
Kotter, J, Rathgeber H., Mueller P. 2006. Our Iceberg is Melting:
Changing and Succeeding Under Adverse Conditions. St Martin’s
Press.

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Close Call: An Interpreter’s Story
SAY:
Here is an example of a close call that we experienced here. This
story comes from (specify source, eg: interpreter services, nursing,
or patient safety, etc.)
“The patient came to the surgery, and it was assumed that the
patient did speak English. After the whole assessment was done,
the patient answered inappropriately, and that made the nurse
doubt. She called interpreters, and I arrived. And the nurse said
‘you said you’re not allergic to medicine….drug or latex’ And when I
interpreted, [the patient] said, ‘I am allergic to latex’. …And the
nurse kept saying, ‘Are you sure?’ and she said, ‘Yeah…’ ‘And what
happens to you?’’ Well they put the latex band…it was itchy, it was
red, and it was swollen.’ So she had to stop, run, call the OR, put on
the latex sensitivity. They had to move everything from the OR.”

Slide

INSTRUCTOR NOTE:
Please replace this story with a local story from one of your clinical
settings, in which an LEP patient was at risk or was harmed due to
problems with cultural differences or missed communication. You
will likely discover stories of close calls or risky situations if you
speak to frontline staff members or leaders in nursing, interpreter
services, or patient safety.
If you do not have a local story to share, you may use the example
above and say:
“As part of the preliminary research that was done for this Training
Module, 18 persons were interviewed in 3 hospitals among frontline
staff and leaders in interpreter services, nursing and patient safety.
All 18 persons reported situations where an interpreter was needed
but was not present. In several cases, this led to “close calls” like
the one described on this slide”.
Here is another possible example you could use instead of the one
in the slide:
LEP Patients at Risk – A Nurse’s Story
“I have noticed that the patients come back to the hospital, to the
same units where they have already been discharged. So you give
the paperwork to the patient the day that they are going home. The
patient actually said, “yes yes yes yes I understand everything”.
And then you find the patient back a few days later, a week
later…the same patient. And then, that’s when I find out that every
discharge instruction that was given to the patient was totally
misunderstood”
TeamSTEPPS | Limited English Proficiency

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Scenario
SAY:
This video gives us an example situation in which a patient with
limited English proficiency is at risk.

Slide

VIDEO TIME:

DO: Show the “opportunity” video.

4 minutes
DISCUSS:
Ask participants: What are the risks in this situation? What was
handled badly? What important information was missed? What
could be done differently? Allow them the opportunity to discuss
and respond. If they do not respond, prompt them with
suggestions:
Let’s start with the front desk –
What might the triage nurse have known about words that sound
familiar in foreign languages?
At what point should a professional interpreter have been called
in?
At what other points were there missed opportunities to call an
interpreter?
What else could the care team have done to better communicate
with the patient and his wife?

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Benefits of including interpreter on the care team

LEP

SAY:
When we include a professional interpreter as a member of the
care team, there are significant benefits to the patient.
Of course, the interpreter can interpret the words spoken or
translate written words. The interpreter can also serve as a
cultural broker, helping healthcare providers understand the
cultural perceptions and expectations of the patient as well as
helping the patient understand the expectations and culture of
healthcare. Finally, the interpreter can also serve as an advocate,
speaking up when they feel the patient or provider may have
missed important information.

Slide

The presence of a professional interpreter also has significant
benefits to the care team, ensuring that the the care team has
more accurate and more complete information, and facilitating
decision-making.

INSTRUCTOR NOTES:
It can also be beneficial to use bilingual staff who are certified to
provide care in non-English languages, or volunteers who are
trained and certified to act as interpreters.

Some health care settings advocate a “Black Box” model, where
the interpreter limits themselves to interpreting and translating
words. However, patient safety can be enhanced when the
interpreter is also allowed share important cultural information and
raise patient safety concerns.

TeamSTEPPS | Limited English Proficiency

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Implementation
SAY:
What is the process for obtaining an interpreter in your clinical
area?

Slide

The basic steps include identifying the need for language or
cultural support, contacting the interpreter, ensuring that the
interpreter remains present during the entire patient encounter,
and ensuring that the interpreter is fully informed and integrated
into the patient care team. Also, there needs to be way of
implementing contingency plans as needed, for example if the
interpreter is late, or if the interpreter needs to leave before
encounter is complete.

EXERCISE:
Instruct participants to take out their worksheet (provided as
part of the Training of Trainers) and to take five minutes to
complete the map, adding any steps necessary at their site and
noting who, when and how. If there is a team from one unit or
area, they can work together to complete the worksheet, or
they may use a flipchart for easy viewing by the whole group.
Once they have completed the sheet, ask the groups to share
their detailed maps with the full group, closely monitoring time
(5 minutes).

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Assertion, Advocacy and Conflict Resolution

LEP

DO:
Read the scenario

DISCUSS:
Slide
What are the risks to the patient in this scenario?
What could go wrong?
What needs to happen to avoid problems? If you were Ms.
Solaine, what could you do?
(Allow time for group to answer questions and discuss. If no
one speaks up, call on a few people by name to encourage
responses to these questions).
SAY:
Specific skills needed in this scenario include assertion,
advocacy and conflict resolution. We will learn some
structured methods of assertion that might help in situations
like this.

INSTRUCTOR NOTES:
Two main languages are spoken in Haiti, Haitian Creole and
French. Speaking French signals a higher social status.
Thus, some patients may be reluctant to admit they do not
understand it well.

TeamSTEPPS | Limited English Proficiency

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Advocacy and Assertion
SAY:

Slide

Advocacy and assertion are useful for any team member whose
viewpoint does not agree with that of a decision maker, or who
notices a patient safety problem. In advocating for the patient and
asserting a corrective action, the team member has an opportunity
to correct or avoid errors. Failure to use advocacy and assertion
has been frequently identified as a primary contributor to the
clinical errors found in malpractice cases and sentinel events.
DISCUSS:
When might you use advocacy and assertion for LEP patients?
• To make sure that patient language needs are assessed
• To make sure that an interpreter is called when needed
• To raise communication issues
SAY:
When advocating, assert your viewpoint in a firm and respectful
manner. You should also be persistent and persuasive, providing
evidence or data for your concerns. Appropriate assertion is a
way of advocating for the patient. In the interest of safety, you may
need to speak up to stop all patient care activity until a risk can be
resolved or until the patient understands what is happening. In this
session, we will show you structured language and gestures that
can make it easier to be appropriately assertive.
It’s helpful to note that assertion is not aggression: assertive
statements respect and support authority.
DISCUSS:
Why might it be difficult to speak up on behalf of the patient? (Allow
the group to respond). Some possible reasons include the
traditional hierarchy of healthcare, the strong personalities of some
healthcare providers, previous negative experiences with speaking
up—if you have tried it once and been “shot down” you tend to be
very hesitant to speak up again even in a different setting with
different people. Cultural differences are also a factor in the
difficulty with assertion, because deference to authority is an
important value in many cultures.

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Assertion at Work

Slide

DO :

VIDEO TIME:

Play the Assertion video (this is the segment of the
success LEP video that involves the interpreter
putting up hands to stop the conversation, stating
that there is a misunderstanding of the word fatiga,
and clarifying what the patient is saying)

15-30 seconds

DISCUSS:
Was the assertion respectful? Did it follow the steps listed here?
•
•
•
•
•

Make an opening: using the hand signal agreed upon to
mean “please stop and listen”
State the concern: “I think there’s a misunderstanding”
State the problem: “You are interpreting ‘fatiga’ as fatigue but
I think he means shortness of breath”
Offer a solution: “Let me check with him to clarify”
Reach an agreement: “OK?”

What do you think will be the result of this assertion?
What risks might it prevent?

TeamSTEPPS | Limited English Proficiency

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Stop the Line: CUS

SAY:

Slide

Structured language can make it easier to speak up and be
assertive when it’s needed. By using a “script” of set
phrases that the team has agreed upon in advance,
interactions are more predictable and less “personal”.
In TeamSTEPPS when we need to “stop the line” to ensure
safety, we “CUS”. The team understands that when any
member of the team says, “I’m concerned…I’m
uncomfortable…”This is a safety issue” it means that we
need to pause and make sure that there are no unnecessary
safety risks happening, and that the entire team understands
the plan.
The phrases function as a signal, similar to calling a code.
Hand signals or gestures are also useful as “code” language
for interpreters (or others) to indicate a need to stop and
listen. Raising the hands in front of yourself, palms out, can
be an agreed-upon gesture to “stop the line” for interpreters.
Here’s an example:

VIDEO TIME:
15-30 seconds

DO: Show CUS video clip (this will be a 15-30
second clip from the video we will produce).

DISCUSS:
Was the use of CUS effective? Why?
SAY:
You can also use these signal phrases to escalate a
concern. first state that you are concerned, then if there is
no response, you can go on to say you are uncomfortable or
that this is a safety problem. It’s important to give as much
information as you can regarding why you are concerned,
and what you are seeing or hearing that is making you
uncomfortable.
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When Initial Assertion is Ignored…
SAY:
It is important to voice your concern by advocating and asserting
your statement at least twice if the initial assertion is ignored
(sometimes it is called the “Two-Challenge rule”). These two
attempts may come from the same person or two different team
members. The first challenge should be in the form of a question
or initial concern. The second challenge should provide some
support for your concern. Remember this is about advocating for
the patient. This "two-challenge" tactic ensures that an expressed
concern has been heard, understood, and acknowledged. If, after
two attempts to clearly assert your concern, there is no resolution
of the problem, you may then seek assistance from an additional
resource, such as a charge nurse or other physician.

TeamSTEPPS | Limited English Proficiency

Slide

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Briefs
SAY:

Slide

Once the full team is present and engaged, it’s necessary to
ensure all are informed. This includes the interpreter. Briefs are a
communication and team tool for planning purposes. During a
brief, which is sometimes referred to as a team meeting, complete
the tasks listed on this slide.
The team leader is responsible for organizing a short briefing to
discuss essential team information and to establish an
environment in which the team, including the interpreter and the
patient, are comfortable speaking up and participating. The
following information should be discussed in a brief:
• Team membership and roles—who is on the team (including the
interpreter) and who is the designated team leader
• Encouragement to speak up and share any relevant information
or concerns
• Team goals, plans and risks—what is to be accomplished and
who is to do it, what are the potential risks

VIDEO TIME:
30 seconds

DO:
Play the video by clicking the director icon on the slide.
(Use the segment of the success LEP video in which the brief
occurs, including the interpreter)

DISCUSS:
• Who is the team leader?
• How did the leader establish psychological safety for the team?
• Did the team develop a plan for the patient?
• Did everyone understand the plan?

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Psychological Safety
SAY:
The team leader establishes psychological safety for the group:
the INTERPRETER establishes this for the patient . This is the
way we create an environment in which is is safe to speak up.
Traditional hierarchy, status differences, and cultural differences
can create real barriers to effective team communication. It is up
to the leaders of a team to overcome that through these
strategies.

Slide

Leaders invite comments by calling on team members by name
and by role: “Gerardo, as the interpreter, do you see anything
here that we’ve missed or that Mr. Ruiz may not understand?” or
“Jane, as Mrs. Ruiz’s nurse, do you have anything to add?”
Leaders also are perceived as more accessible and approachable
if they validate the comments of the team. “Mr. Ruiz, it sounds like
you are concerned about this.” Leaders also recognize that all
humans can make mistakes and they ask for mutual support to
avoid error. You can do this in your own words, for example: “if
you see anything that seems risky or that you don’t understand,
please let me know”, or “feel free to stop us at any time if anything
is not clear, or if there is anything I should know about the
patient's culture, beliefs or concerns”.

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Practice
SAY:
We’re going to practice briefing, including creating psychological
safety.

Slide

In this scenario, the patient is being discharged from the hospital
after having a myocardial infarction. The interpreter introduces
herself to the provider and the patient. The nurse asks the patient
and interpreter to let her know if there is anything the patient does
not understand, or anything that makes her concerned or
uncomfortable. The interpreter interprets this and also asks the
patient to let her know if there is anything he does not understand
or is concerned about. You should feel free to rephrase this in
your own words.

EXERCISE:
In small groups, practice (role play) the scenario, leading a
briefing and using name and role activation and requesting direct
input. Then debrief the exercise as a full group.

SAY:
Please note that in some cultures, the patient may prefer to have
the provider and interpreter address a family member instead of
addressing the patient directly. The interpreter should verify the
patient’s communication preferences and may provide guidance
to the provider about whom to address and how.

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Check Back is…
SAY:
A check-back is a closed-loop communication strategy used to
verify and validate information exchanged. The strategy involves
the sender initiating a message, the receiver accepting the
message and confirming what was communicated, and the sender
verifying that the message was received.

Slide

A simple example of this is in the coffee shop when you order a
tall nonfat soy latte, and the cashier says aloud, “tall nonfat soy
latte” and the barista repeats back “tall nonfat soy latte”, and you
verify, “that’s correct”.
A clinical example would be an information call-out “BP is falling,
80/48 down from 90/60.” The sender expects the information to be
verified (repeated aloud) and validated and to receive a follow-on
order that must be acknowledged with a check-back.
In the video, you will see a provider using check-back to confirm
their understanding of what the patient was saying.

DO: Play the video by clicking on the top director icon on
the slide. (Use check-back clip from the “improvement” video)

TeamSTEPPS | Limited English Proficiency

VIDEO TIME:
15-30 seconds

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Teach-back is…
SAY:

Slide

While check-back simply verifies accuracy of a simple
communication, teach-back is a method to confirm understanding
of larger concepts or processes. In a teach-back, you ask
someone to tell you in their own words what they have learned or
understood.
This technique can be most useful for interpreters, who can use
the teach-back to correct any misinformation or missed
communication.
Examples include asking the patient to tell how they will take their
medication when they get home, or how they will explain their
illness to their family.

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Putting It All Together

Slide

DO: Play the “Opportunity Won” video by clicking on
the picture

VIDEO TIME:
4.5 minutes

DISCUSS: What tools were used in this version that were
not used in the first version of this scenario? How did the use of
those tools change the outcome?

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Summary
SAY:

In summary, here are tools and strategies which can enhance the
safety of your patients with LEP:
Slide
• Process for including interpreters
• Brief/ Psychological Safety
• Advocacy and Assertion
• CUS
• Check-Back
• Teach-Back

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LEP

Training Evaluation
SAY:

Thank you very much for your participation today. Please take a
few minutes to complete the training evaluations that are in your
training packets, then we will discuss this module. Everyone
should complete two forms: the training participant satisfaction
survey and the learning outcomes survey. We anticipate this will
take you no more than 15 minutes.

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POSTTRAINING
EVALUATION
Slide
TIME:
15 minutes

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10 minutes

Slide

Review the Teaching Points

Discuss:

Having experienced the module, what questions do you have
about the content?

What parts will be easiest for you to teach?

Which parts will be harder to teach? Why?

Where will you want to customize the module for your group?

What concerns were raised for you as you experienced the
module?

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LEP

Review the Instructor Guides
DO:
Hand out the module Instructor Guides to participants, or direct
them to that segment of their packet.

SAY:

5 minutes

Slide

This guide provides you with a possible script to accompany the
slides, and also indicates areas where you can customize the
material. Additional resources and references are also provided.
As we go through the guide, please note the places where you
would want to customize the content.
DO:
Go through the guide briefly, answering questions and clarifying
symbols.

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Implementation
NOTE:
The TeamSTEPPS LEP implementation slides are used in the
following segment, which will take about 35 minutes to complete.

Slide

SAY:
For this portion of the training, you need to be in groups with the
others from your organization, so that you can work together on
the activities and worksheets.

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Implementation: Shift Towards a Culture of Safety

LEP

SAY:
This diagram provides an overview of the implementation of any culture
change, and of any TeamSTEPPS intervention. If you have done other
TeamSTEPPS work in your organization, you are probably familiar with
this process. We’ll review it very briefly: there are three phases of any
successful implementation—Assessment, Planning/Training/Action, and
Sustainment. You can think of it in simple terms by following the bottom
of the diagram: Set the stage, Decide what to do, make it happen,
make it stick.
In phase I, assessment, you use what information you have to
determine readiness and to inform you planning phase. For this
intervention to improve the safety of LEP patients, you’ll use the site
assessment you completed prior to training, along with the data you
have about LEP patients at your organization. You can include any
culture survey data you might have, such as patient satisfaction survey
information if it can be segmented by language or cultural needs. If the
results of your assessment indicate readiness, then you move into
action planning—and we will do that today in this module. You’ll leave
this session with an action plan for your implementation.

Slide

5 minutes

Only after assessment, review of the information, and action planning
are you ready to plan your training. Just training, by itself, is not
sufficient to implement a change in safety culture. Your staff probably
won’t be motivated to change their behavior in terms of accessing
language services and integrating interpreters on the care team with just
training. You have to build in a change in the way things are
done…that’s the intervention. Then you test your intervention, on a
small scale, to see if it needs any adjustment prior to implementing. If
you are changing the way you call for an interpreter, for example, do
that in just one unit or on just a few days to see if the process you’ve
decided upon really works well. Then, once it’s been tested and
improved, you can actually implement the change. Build your training to
prepare people for the change in behavior and the change in practice.

Monitoring the measures you choose during assessment is a way of
building in sustainment, and in making your changes stick. So is the
use of coaches. We will provide you with some information about
choosing and training your coaches later today….but this is the basic
process you’ll be using now to plan your changes and your training.
(5 min)

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Implementation Phase I - Assessment
SAY:
We will now work through the first phase, assessment, using your
prework materials.

Slide

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Implementation: Patient Language Process Map

LEP

SAY:
Let’s start with your Patient Language Process Map. Take out the
one from your prework assessment, as well as the one completed
today when you experienced the LEP module. You have in your
packet two blank worksheets of this map. On the first one, take
five minutes minutes with your group to reach consensus on the
current process in your clinical area. Complete the worksheet by
answering these questions. (5 minutes)

Slide

SAY:
Next, based on what you have learned so far, now work together
to create another process map of the ideal, safest process for
meeting the language and cultural needs of your patients. Take 5
minutes to complete the worksheet as a group, writing in the way
it could be once all the changes are complete. (5 minutes)

10 minutes

DISCUSS:
What are the gaps that you identified, and how will they be
addressed in the ideal version of the process map?

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Implementation: Policies and Guidelines
SAY:
Now we will consider policies that govern use of language services for your
patients.

Slide

10 minutes

The Patient-Centered Communication standards from The Joint
Commission were approved in December 2009 and released to the field in
January 2010. The standards will be published in the 2011 Comprehensive
Accreditation Manual for Hospitals (CAMH): The Official Handbook. Joint
Commission surveyors will evaluate compliance with the Patient-Centered
Communication standards beginning January 1, 2011; however, findings will not
affect the accreditation decision. The information collected by Joint Commission
surveyors and staff during this implementation pilot phase will be used to
prepare the field for common implementation questions and
concerns. Compliance with the Patient-Centered Communication standards will
be included in the accreditation decision no earlier than January 2012.
Advancing Effective Communication, Cultural Competence, and Patient- and
Family-Centered Care: A Roadmap for Hospitals is a monograph developed by
The Joint Commission to inspire hospitals to integrate concepts from the
communication, cultural competence, and patient- and family-centered care
fields into their organizations. The Roadmap for Hospitals provides
recommendations to help hospitals address unique patient needs, meet the
new Patient-Centered Communication standards, and comply with existing
Joint Commission requirements. Example practices, information on laws and
regulations, and links to supplemental information, model policies, and
educational tools are also included. The Patient-Centered Communication
standards will be presented in a separate appendix that provides selfassessment guidelines and example practices for each standard. Additional
information about the Roadmap for Hospitals is available from the project Web
site: http://www.jointcommission.org/patientsafety/hlc/.
Consider these requirements along with your hospital policies which you have
included in your prework site assessment. Take five minutes to review the
policies with your group and make notes of any changes in policy that would be
needed if your ideal process for meeting patient language and cultural needs
were implemented. Also make notes of any relevant current policies that are
not being followed in your current process. (5 minutes)

DISCUSS:
Did you identify any relevant policies that are not being followed right now?
What are some examples of policy changes that would be needed if your ideal
process were implemented?

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LEP

Site Assessment
SAY:
In your planning you will need to consider your data—for example,
the percentage of your patients who have limited English
proficiency or the most common languages spoken by your
patients. You’ll also want to consider additional information about
your hospital, your unit, and your patients with LEP, information
that may not show up in the data. These may be stories or
examples of specific incidents involving LEP patients, particular
patterns of cultural bias or conflict in your area, and general
attitudes about diversity and inclusion.
ASK:

Slide

5 minutes

What other information needs to be included in planning changes
for your process of meeting the language and cultural needs of
your patients? Take five minutes to discuss with your group any
other information from your prework that needs to be considered
as you plan. Also make notes of any additional information that
you may need to collect. (5 minutes)

DISCUSS:
What other information will you need to consider?

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Phase II: Planning, Training, Implementing
SAY:
Now we move into planning the changes and the training.

Slide

36

You will define your goals and identify measures that will indicate
progress toward those goals. You will target specifically what
processes and behaviors need to change, and strategies for
making those changes, and you’ll plan the logistics and
customization of your training.

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LEP

Goals and Outcomes
SAY:
Return to your process maps of the current process and the ideal
process. Using those in your group, take five minutes to identify
specific changes that are needed, and to write them on the
worksheet.

Slide

5 minutes

MATERIALS:
• Worksheet
handouts of this
page
• Process maps
completed earlier

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Evaluation
SAY:

Slide

MATERIALS:
• Evaluation Guide
• Evaluation
worksheet

38

Evaluating your TeamSTEPPS module can help you to figure out
if the training did what it was supposed to do, and if not, it can
help you improve the training over time. A good evaluation will
document your efforts and the efforts of all staff involved, describe
any ways in which you may have adapted the Module to your
hospital’s needs, test whether the intervention worked, help you
find ways to improve the intervention, and help you increase buyin from staff members and senior leaders. It is a very important
step toward the sustainment of your TeamSTEPPS intervention.

As part of this training, we are sharing with you an evaluation
guide that we hope will be helpful to you in your evaluation task.
The guide discusses the purposes of evaluation, what options you
have to design your evaluation, how to do a process evaluation,
what metrics you can use to measure your success, and how to
analyze the data. Over the next few weeks, we will follow up with
you by phone to learn how useful the evaluation guide is or isn’t,
how it might need to be modified, and what kinds of support you
might need to use it. The tool will be revised based on your
experience, and in future trainings of trainers we will spend more
time discussing it. For now, we will discuss a few highlights.

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LEP

Evaluation
As part of your implementation process, you’ve defined one or
more goals for your TeamSTEPPS intervention. Then, you will
need to select an evaluation design that minimizes the likelihood
of biased results. The evaluation guide explains several study
design options you can use.
The best and most expensive study design is a randomized
controlled trial, where you randomly select some units to get the
interventions and others not to get it, and compare results for both
implementers and non-implementers. A less rigorous but cheaper
option is to implement the evaluation in one or more units, and
compare results in those units to results in units that did not get
the intervention. Finally, the cheapest and most common study
design is where you implement the training in a single unit and
collect data before and after the intervention. That study design is
a little weak, because changes before and after the training could
be caused by some outside factor other than your intervention.
However, it may be the most feasible option for many change
teams.

Slide

As part of your evaluation, you’ll want to document to some
degree the process that you’re following to implement the module,
for example by looking at what the costs are, how many people
you’re training, any challenges you’ve encountered, and anything
else that’s going on at the time of the intervention that may affect
results. That is the process evaluation. There is a 1-page
template in the evaluation guide that walks you through a basic
process evaluation.
It’s also important to collect and analyze quantitative data based
on specific metrics to document your success. The metrics
should be selected based on what you think you can accomplish
as a result of the training. Typically, we look at four levels of
evaluation metrics. Level 1 is trainees’ immediate reactions; level
2 is trainees’ level of knowledge; level 3 is staff behavior changes
that happen as a result of the changes; and level 4 is the final
result, which may include patient satisfaction, staff satisfaction,
patient health outcomes, and other indicators of the quality and
safety of care. The higher up you go in the evaluation levels, the
stronger your evidence will be.

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Slide

Evaluation
When you experienced the training module as intended for
trainees, you completed evaluation forms to assess your reaction
to the training (which is Level 1) and test your knowledge (which is
Level 2). You can use these same metrics to evaluate your
TeamSTEPPS intervention in your hospital. In addition to
measuring reactions and learning, I encourage you to use the
other metrics in the evaluation guide to measure behavior
changes and patient outcomes resulting from the training.

You can customize your evaluation to use other data you may
have available at your hospital, such as existing patient or staff
satisfaction surveys, interpreter utilization data, patient safety
data, or data about specific health care outcomes you hope to
change as a result of this training. The key is to choose
indicators that are likely to improve as a result of your
TeamSTEPPS intervention.

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LEP

Your Evaluation Plan
SAY:
Now I’d like you to think about your own evaluation , and use this
sheet to record your thoughts today.

Top left, what do you hope to accomplish by implementing the
TeamSTEPPS module? That is your intervention goal.

Just below that, I’d like you to record what study design you think
you can do. Most sites choose the single unit pre-post study
design because it’s the easiest and cheapest option, although the
evidence that this produces is a little weak. However, if you will
be implementing the Module in several units, you might consider
using one or more comparison groups, which produces better
evidence. Finally, if you will be implementing in many units, the
evaluation is well-funded, and you want really solid results, you
might consider a randomized controlled trial. Off the top of your
head, which of these designs are you most likely to choose?

Slide

10 minutes

Next, will you do a process evaluation? Doing a process
evaluation can help you tell the story of your TeamSTEPPS
intervention, which is important to communicate with decisionmakers at your hospital. The process evaluation can be a fairly
simple record of the resources you invest, the activities you do
(for example, how many trainings you do), your outputs (for
example, how many people took the training), and your
experience (how well it went). There’s a 1-page template showing
how to do this in the evaluation guide. Is this something you think
you can do? If yes, write “yes” it down here.

Finally, what metrics will you use to assess whether you have
reached your intervention goals? At the very least, we
recommend you use the Level 1 and 2 metrics from the evaluation
guide, which you experienced when we shared the module with
you. Will you use these metrics? If so, write it down.

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Evaluation Plan
SAY:

Slide

42

The examples of metrics and assessments listed here are
available in your Evaluation Guide. Evaluation of your
intervention will provide feedback that is helpful in sustaining
change. Well-designed and well implemented evaluation plans
may produce publishable results that will not only help your
clinical area, but also healthcare across the U.S. The evaluation
guide provides you with study designs that may be used to
evaluate in this way. Now, take five minutes to write in the
measures you will use to evaluate the effectiveness of your
intervention.

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LEP

Training
SAY:
Now that you know what changes you want to implement and how
to measure the success of those changes, you are ready to plan
your training. Take 10 minutes with your group to discuss the
logistics of your training. Who will be trained? Interdisciplinary
teams? How will you get everyone together for the 60 minute
session? How long will it take to cycle everyone through training?
How will you handle training night shift?

Slide

10 minutes

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Phase III: Sustainment
SAY:
Now consider how you will “make it stick”. How will new staff be
trained? How will these changes become “institutionalized” and
permanent?

Slide

One element that can help support behavior change long term is
the use of coaches: people within the unit representing the
different professions and disciplines, including interpreters, who
agree to help their peers use the new tools and processes.
Internal coaches receive extra training and support, and are the
ones who provide effective, respectful feedback in the midst of the
work that can help keep the team on track. For example, a coach
in a clinical area who works at the front desk as unit clerk might
remind the nurse, “we agreed to call language services first when
a patient comes in and we are unclear about their language
needs, remember? Let’s do that now….” Or a coach who is an
interpreter might debrief with another interpreter, encouraging
them to use assertion skills in future. There is a coaching module
on your cd and in your packet that has been customized for use
with this module on safety for patients with limited English
proficiency, and we encourage you to use that to help you prepare
for sustaining your changes and improvements.

Another element that can help with sustainment is planning to
address possible barriers and objections. An additional resource
for this is included in your handouts, taken from AHRQ’s Informed
Consent and Authorization toolkit.

Planning ongoing training and refresher courses also helps it
“stick”, as does consistent feedback and encouragement from
leadership.

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LEP

Action Planning
SAY:
Take 20 minutes in your group to complete your action plan for
implementation, using all the information you have gathered and
discussed so far. Include all the steps of the plan, who will be
responsible for each step, and a target time frame for each step.
Use the worksheet provided. We will be available to help your
groups as you complete the action planning.

20 minutes

Slide

DO:
Ask the groups to share their action plans with each other.

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Practice Teaching
SAY:

40 minutes

Slide

For our practice teaching segment, you will be assigned one slide
from the LEP module, and you will have a few minutes to review
the instructor guide for that slide and prepare to present that one
slide to the group (or to a small group segment if there are more
than 10 participants in the Train-the-Trainer session).

DO:
Assign each participant one slide from the set.
Allow them 10 minutes to work individually with their instructor
guides preparing the material to present.
Then have them present their slides in order, with one minute per
slide. Provide encouragement and suggestions, and give them
assistance with navigating the cd and the slides.
Debrief with the group, praising good presentations with specific
feedback.

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Evaluation of the Train-the-Trainer Session

LEP

SAY:
This concludes our training of trainers for the LEP Patient Safety
module. Thank you all for your participation. We would be very
interested in your honest feedback, which will help us continue to
improve this session.

15 minutes

Slide
DISCUSS:
What questions do you have about the training?
What worked in this training of trainers?
What could be improved?

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