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K698 Quality Improvement Project

Eskenazi Grassy Creek Health Center
Jaclyn DiBartolomeo

I. Stage I: Need Identification

I had the opportunity and privilege to rotate through Eskenazi Grassy Creek
Health Center for my community medicine rotation. Throughout my rotation, I
was able to learn from the outstanding providers and see how their clinic
functioned. The clinic at Grassy Creek was a very fast paced environment
and providers were allotted 15-30 minutes for each appointment. At Grassy
Creek, providers need to be efficient and use their time wisely, in order to see
patients on time and provide them with exceptional care. Most of the time,
providers would fall behind on the schedule due to the high volume of
Spanish speaking patients and the lack of interpretation resources available.
This resulted in longer wait times for the patient, rushed appointments, and
overall a lower quality of patient care. In addition, the interpretation services
were not always reliable or available to use for the providers. I believe that
improving the interpretation resources would benefit Grassy Creek Health
Center and provide the patients, specifically the Spanish speaking patients, a
better experience.

The clinic had one “in house” Spanish interpreter in the office. Aside from the
one Spanish interpreter, the office had a dedicated phone line for
interpretation, with 2 phones. During my time at Grassy Creek, there was only
one working, because there was an issue with the battery and charging
stations. Lastly, there was one Martti interpretation machine that could be
wheeled into patient rooms and offered a video chat with an interpreter. Both
the phone lines and Martti were unreliable, with sometimes having long hold
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times, getting frequently disconnected, or not charging adequately. In

addition, the phone lines were very muffled and unclear when on speaker
phone.

The underlying cause of the of the longer wait times, decreased patient
satisfaction, inefficiency in translation services, and a rushed provider during
appointments is due to the combination of too few interpreters for a high
Spanish speaking patient population as well as unreliable translation services
(phone lines and Martti). Often times, it was hard to find the “in house”
interpreter because she would be in another room with another provider for
15-30 minutes, so you have to either call the interpreter phone line or find the
Martti. The providers were not thrilled with using the phone line, because
many times there would be a long hold before getting in contact with anyone,
and when they did get in contact with someone, it would be very hard to hear
them clearly. The process would overall take up to 20 minutes just to get
connected clearly with an interpreter. This decreases patient satisfaction
because they are not seen on time, decreases quality of care because it is
hard to understand the interpreter on the phone and overall resulted in poor
communication between the provider and the patient. Lastly, it puts the
provider behind schedule, causing providers to rush and not get time to chart
review or write their notes.

In attempt to improve the efficiency of the interpretation services at Grassy

Creek Health Center, I plan to implement iPads or tablets in each patient
room with translation services installed. These tablets will have patient
questionaries that are straightforward for the patient, and that can be offered
in any language. The patients can fill the questionnaire out in their language,
and it can be translated and uploaded in the EMR in English. This would give
the provider an idea for why the patient is here, and answer specific
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questions related to their chief complaint, symptoms and their past medical
history. In addition to a patient questionnaire, the provider could type out their
own questions specific to the chief complaint before the visit, and have the
patients answer the questions. There could be specific templates designed
for certain visits, such as well child check visits for specific ages, diabetes
check ups, or hospital follow ups. The provider could then review the patient’s
answers in English on the EMR and prepare for the patient interview, physical
exam and discussion of their plan. Following the review, the provider could
then go to the patient’s room and ask them direct questions about their chief
complaint and could interview the patient. This is where I believe the provider
would benefit from an in house interpreter. If the budget allows, it would be
helpful to have five in house interpreters in the clinic at all times. With the high
volume of Spanish speaking patients, this is essential for providing these
patients adequate and high quality care. With the tablets and iPads, most of
the questions could be answered before the provider interviews the patients,
which would mean the interpreters will be used for a shorter amount of time
with the provider for the patient interview. In addition, I think it would be
helpful for the in house interpreter to be able to be present during the physical
exam so they can explain things directly to the patient.

My desired outcome for this implementation is to have better patient care to

the Spanish speaking population, as well as any other patient that speaks a
language other than English, and to have more effective communication
between the provider and the patient, despite language differences. In
addition, this would cut down appointment wait times and allow the providers
to see patients on time and in a timely matter. Overall, this implementation for
improving translation resources would improve office workflow and patient
satisfaction.
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II. Stage II- Determine intervention/Implementation

The likeliness of success of this intervention depends on the budget of

Grassy Creek as well as the cooperation between all team members. If the
budget allows for iPads or tablets in the patient rooms, then the office would
need to hire an IT department to install the translator service on each iPad. In
addition, the service would have to be linked to the EMR, either via dragon or
another charting tool. The team members would need to sacrifice their time to
be trained in this new program as well. This would have to be after clinic
hours, so team members of the clinic would have to sacrifice their time after
work for training. I believe that all team members should be trained in the use
of the tablets and the interpretation system installed on the tablets (this
includes administration staff, pharmacists, social workers, nurses, medical
assistants and providers). I think that after this new interpretation intervention
is installed, that there should be a survey on each of the tablets for the
patients to fill out at the end of the visit. This could track the patient outcomes
and satisfaction and could lead to ideas for improvement. At the end of every
month, team members could go over these results from patient’s surveys and
discuss what can be improved.

I think that all patients could use this program, whether they are English or
Spanish speaking. I believe this program can improve wait times in the clinic
because they are questionaries that are straightforward and can save time
when taking the patient’s history. However, I think it would be helpful to
determine if a patient is Spanish speaking before they even come in for their
appointment and to put it next to the “reason for appointment” or to have a
certain color designated for Spanish speaking patients. With labeling peoples
languages before the appointments, providers can see how many Spanish
speaking or non English speaking patients they have for the day when they
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get into the clinic in the morning, which will help them better prepare for their
day and manage their time.

To assure necessary resources depends on the budget of the clinic. This

would mean either selling the Marttis or disconnecting the phone lines to save
money. In addition, an IT department staff member should be in the clinic
during clinic hours to troubleshoot any technical difficulties. This could be
costly as well, but I do believe that it would be beneficial for the first few
months of this implementation. I do understand that this is an expensive
implementation, so discussing the budget with a financial advisor or
accounting member of the clinic would be beneficial. If the proposal is too
costly, then an idea would be to only get a few iPads, instead of one in every
room, and reserve them for the non-English speaking patients only.

Another implementation that could be done at first, is to schedule Spanish

speaking patients or non-english speaking patients a longer appointment
time. This could be as simple as scheduling them for 45 minutes instead of
30, just so the provider can have time to set up the interpreter. This would be
an idea before the iPads could be implemented or before another interpreter
is hired.

III. Stage III- Evaluate Outcomes

The ultimate goal of this intervention is to improve the quality of care and
patient satisfaction at Grassy Creek Health Center. In addition to better
patient satisfaction, providers and health care providers at Grassy Creek will
be satisfied knowing that they have resources for interpretation and that they
can see patients in a timely matter. This will decrease stress for the providers
and allow for better patient care. I think that this implementation will also
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provide more effective communication in terms of diagnosing and treating the

patients.

I think that evaluating these outcomes should be done monthly for the first 6
months, and then every 3 months after that. All staff should have a meeting
where they can review the survey results and address any concerns or ideas.
IT members should be present as well for any questions regarding the
technology. I think that monthly meetings and analyzing surgery results would
be beneficial in tracking the outcomes of this implementation.

Overall, improving interpretation resources will improve the Spanish speaking

populations quality of care and the providers ability to communicate
effectively with the patient. This will provide greater patient and provider
satisfaction. I think that this will allow this fast paced clinic to function more
smoothly.