Intervention Title:
Working in Health Care Organization Teams: Language Services' Participation in Root-Cause Analysis Process – Phoenix Children's Hospital; Phoenix, Ariz.

Goal:
Reduce the risk that language barriers pose between patients and providers, and address the factors that contribute to an adverse and preventable event.

Innovation:
The Language Services Department is now an active participant in the hospital's standard review process that takes place immediately following a near-miss or sentinel event involving a limited English-proficient (LEP) patient or family member.

Result:
Because Language Services staff now participate in the root cause analyses that involve LEP families, a wider range of experience and expertise is used to analyze system solutions and work toward eliminating preventable harm to patients.

Institution:
Phoenix Children's Hospital
1919 E. Thomas Road
Phoenix, AZ 85016
P: (602) 546-1000

From the C-Suite:
“Participating in this review process has benefits that extend beyond discovering what contributed to this single event and how such circumstances can be avoided in the future. It helps to educate those who participate in the reviews—physicians, nurses, registration staff, pharmacists, social workers and others—about process and systems related to language needs. It identifies the importance and critical need for Language Services throughout the facility.”

Murray Pollack, M.D.
Vice President, Medical Affairs and Chief Medical Officer

Profile:
Phoenix Children's Hospital is one of the 10 largest, free-standing children's hospitals in the U.S. with 299 licensed beds, approximately 12,000 annual admissions and nearly 60,000 annual Emergency Department visits.

Clinical areas affected:

• All

Staff involved:

• Language Services
• Nurses
• Physicians
• Quality Council

Timeline:
The time span from the idea's germination to Language Services representatives participating in a root cause analysis process was approximately six months.

Contact:
Irma Bustamante
Manager, Language Services
P: (602) 546-3352
ibustam@phoenixchildrens.com

Innovation implementation:
The Joint Commission has declared that medical errors are more likely to take place when language barriers exist between families and their health care providers. Traditionally, everyone involved in all aspects of a patient's care—from physicians and nurses, to laboratory technicians and respiratory therapists, to social workers and pharmacists— joins a quality improvement process and meets quickly after a near-miss or sentinel event at Phoenix Children's Hospital to analyze the situation.

In the past, Language Services had never been included in this process. To help identify how language barriers may have contributed to the event, Language Services knew they needed to have both a seat and a voice at the table during such review discussions. Although this idea was well-received, Language Services leadership had to proactively participate in hospital quality-improvement processes, become active members of quality initiatives and then remind key players consistently of the advantage to the hospital of including Language Services leadership in root-cause analyses.

Having a member of Language Services leadership at the table ensures that critical questions about communication are answered, including: Did the hospital respond appropriately to the family's language needs? Were bilingual service, interpreting and translating documented in the patient's chart?

Advice and lessons learned:

1. Start small. Before even broaching the subject of getting involved in root-cause analyses, the Language Services team fostered a relationship with the hospital's Quality Management Department— reinforcing awareness that Language Services plays an important role in the quality of care that patients receive.
2. Develop champions. The Language Services team at Phoenix Children's learned that the strong relationships they had forged with physicians and other health care professionals hospital-wide had a definite impact in bringing them to the table for the root-cause analyses process.

Cost/benefit estimate:
Identifying where the greatest risks occur will help to identify necessary system changes and put policies in place to reduce the risk of future events. While there are no immediate documented benefits, the staff at Phoenix Children's believes that the results will be reflected in the long-term tracking of sentinel/near-miss events involving LEP patients.