Form #4 Form #4 Staff training Guide

TM

Enhancing Safety for Patients with LEP

INTRODUCTION

LEP

Slide
SAY:
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 15 minutes to complete these
surveys.

MODULE
TIME:
60 minutes +
evaluation time
(20 minutes)

EVALUATION:
15 minutes pretraining
15 minutes
post-training

(Collect baseline surveys and thank participants).

INSTRUCTOR NOTE:
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

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

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Limited English
Proficiency

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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TeamSTEPPS 10.10 | Limited English Proficiency

The Story of Willie Ramirez

LEP

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.
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

Slide

Limited English
Proficiency
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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Added risk for LEP Patients

LEP

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.

TeamSTEPPS | Limited English Proficiency

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Limited English
Proficiency

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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TeamSTEPPS 10.10 | Limited English Proficiency

Close Call: An Interpreter’s Story

LEP

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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Limited English
Proficiency

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.

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

Slide

Limited English
Proficiency

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

Limited English
Proficiency

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

LEP

Slide

DO :
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)

VIDEO TIME:
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

13

Limited English
Proficiency

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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TeamSTEPPS 10.10 | Limited English Proficiency

When Initial Assertion is Ignored…

LEP

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

Limited English
Proficiency

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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TeamSTEPPS 10.10 | Limited English Proficiency
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Psychological Safety

LEP

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.
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”.

TeamSTEPPS | Limited English Proficiency

Slide

Limited English
Proficiency

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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TeamSTEPPS 10.10 | Limited English Proficiency
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Check Back is…

LEP

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

Limited English
Proficiency

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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TeamSTEPPS 10.10 | Limited English Proficiency

Putting It All Together

LEP

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

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?

Slide

VIDEO TIME:
4.5 minutes

TeamSTEPPS | Limited English Proficiency

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Limited English
Proficiency

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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TeamSTEPPS 10.10 | Limited English Proficiency

Training Evaluation

LEP

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.

TeamSTEPPS | Limited English Proficiency

POSTTRAINING
EVALUATION
Slide
TIME:
15 minutes

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