Cook County Health

Improvement in Diagnostic Error for Limited English Proficiency (LEP) Patients in a Safety-Net Hospital with Automated Electronic Medical Record (EMR) Tool for Language Preference

Project Lead: Dr. Dhara Amin

Project AIM(s): Decrease errors in preferred language data for patients registering in Emergency Department from baseline of ~15% to 5% from December 2021 to December 2022.  

Narrative Description: 

The contribution and importance of data in order to assess and measure diagnostic safety cannot be overstated. Furthermore, utilization of adverse event reporting with the subcategorization for language preference proved to be challenging but eye-opening. There was a paucity of advocacy within our healthcare system to close the gap with diagnostic delays and the grant has allowed me to create a platform to inform, educate and be a change agent.  There are many competing priorities in public safety net hospital which leaves less time and effort to work of equity in diagnostic excellence which takes time and effort.  The project resulted in the following:

  • Language field now is a required a field at registration. We worked with our Health Informatics team and Information Technology to assure the field is required at every unique encounter registration for Emergency Department (ED) patients.
  • Roll out of iSPEAK signage to improve communication concerning the resources for language assistance services was introduced in the Emergency Department. There is increased visibility and clarity for our patients who are limited English proficiency for what is a legal right of the patients.
  • Novel and collaborative in-situ simulation with our Spanish and Polish interpreters, registration clerks and simulation EM faculty for best practices on asking preferred language to patients at registration. We were able to introduce a standardized and scripted approach to obtaining language preference data from patients with cultural humility.

The grant has allowed me to highlight a latent issue of language injustice and make it an issue that affects patient safety but specifically its’ role in the diagnostic process.  

  • Engagement of more national SIDM leaders/mentors with the skills and knowledge concerning diagnostic uncertainty to give direct feedback concerning the projects. 
  • The project and funding from the grant allowed me to be granted permission to dig deeper into the history of the increasing diversity of the community we serve. When I graphed the language preference data for Spanish speakers and was able to present the line graph showing a dramatic increase in the last 10 years it grabbed the attention of our chief equity and inclusion officer who oversees language services. It has led to an increase for positions for in-person interpreters and the creation of a director of language services. 

The in-situ simulation informed us of the challenges our registration clerks face in obtaining accurate information concerning language preference. Many of them have been working 20+ years and have seen the dramatic increase in LEP patients but have not been trained or provided adequate resources to gather the information accurately. The introduction of signage and a formalization of a script was the start of bringing resources to improve the data collection and the clerks were genuinely eager to continue the work.

  • Conclusions: We were able to decrease errors in language preference data from 15% to 5% and continue to work to zero. We envision obtaining accurate language data from patients will be recognized by all as a key contributor to decreasing safety events. The normalization of English as the default language is deeply rooted in privilege and white supremacy. Staff and the system are challenged to empathize with the experience of a patient who is in pain, distress and terrified but is unable to communicate. Our work is disruptive to the status quo, and we are pushing our hospital leadership to begin making the preferred language of the patient and the utilization of a qualified interpreter as part of the introduction of all adverse safety events. We feel confident progress and improvement can only happen if we are purposeful and deliberate. 
  • Opportunities: We have struggled to incorporate the voice of the community in our efforts. Outside of small focus groups in the Emergency Department we are planning to scale up our efforts to clinics in neighborhoods who are predominantly Spanish speaking. Gaining insight of the patient’s perspective is crucial to the work of decreasing diagnostic error and has been limited when the patients do not speak English. 

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Patient delayed or unable to access care
  • Information gathering
  • Information integration
  • Information interpretation
  • Establishing an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

  • Patient-clinician interaction (includes patient and family engagement)
  • Workflow (includes testing, follow-up, and referrals)
  • Health information sharing and accessibility via health IT
  • Knowledge gaps/inexperience

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)