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QUALITY OR SAFETY PROBLEM

Patients with limited English proficiency (LEP) do not have equitable access to written discharge instructions after clinic-based procedures in their native language, which widens the disparity already felt by this vulnerable population. It has been shown that this leads to higher rates of emergency service utilization and poorer patient satisfaction.^1-3

BACKGROUND

Up until this project, few standardized instructions were currently available following our clinic-based procedures (the most common being cystoscopy, vasectomy, ureteral stent removal, voiding cystourethrogram/retrograde urethrogram, and urodynamics studies). Of the limited instructions available, they were difficult to access by patients and providers did not reliably include these in the patient after visit summary paperwork. Language-concordant discharge instructions improve patient satisfaction and has been carried out by other institutions.^4-6 We used the A3 Lean framework popular at UCSF to develop this project: https://fas.ucsf.edu/sites/g/files/tkssra331/f/wysiwyg/A3ThinkingforVI.pdf

PROJECT OBJECTIVES

The objective is to increase the number of non-English speaking patients who undergo one of the above procedures who receive discharge instructions in their native language to above 50% within the year-long pilot of the project.

INTERVENTION

Interventions for this project include:

• Create a library of standardized discharge instruction for our most common procedures (cystoscopy, vasectomy, ureteral stent removal, voiding cystourethrogram/retrograde urethrogram, and urodynamic studies) in English
• Once created, translate these instructions into our most commonly spoken non-English languages (Chinese, Spanish, Russian, and Vietnamese) using the UCSF translation services available. Note: Google Translate or other online resources were NOT used and are deemed unacceptable for this purpose due to unreliability when it comes to medical translation. We used only the official UCSF translation services at our hospital to ensure integrity and accuracy of all documents.
• Implement physical printed copies of these instructions in clinic to be distributed with printed after visit summaries for appropriate patients
• Conduct nursing in-service training on the importance and use of these instructions following clinic procedures (monthly during the pilot)
• Create an online repository for these translated documents and post a QR code in patient-facing clinic spaces so they may be accessed electronically as well

This project has involved partnering with the clinic management, hospital translation services, and nursing/clinic staff considerably to implement the above interventions and would have been impossible without their immense help. Importantly, physical copies and electronic copies are both available in the event that this population has less access to smart phones or computers at home. Also, each document is available in English as well so the staff can review them with the patient, and family members at home who may speak English more comfortably can help assist as well. All posting and material was approved by the clinic management.

MEASURES OF SUCCESS

Our measures of success include monitoring the use of the documents compared to how many eligible appointments our clinic has, expressed as a percent. This includes monitoring the number of downloads of the digital copies of instructions as well as how many printed documents are handed out. A future metric will include monitoring patient satisfaction scores in this population from before and after implementation, and this will be a reliable measure of our success and has been supported in similar literature. Additionally, we can measure urology patient emergency department visits or patient-advice calls related to clinic-procedures before and after the intervention to measure our success in diminishing preventable utilization of after-hours or emergency care.

OUTCOMES

Expected outcomes include higher patient satisfaction scores in this population following clinic visits, fewer unnecessary/avoidable emergency room visits, fewer after-hours calls to the advice line, and better patient care (although the latter is more of a subjective outcome and inferred from the first three). From a social justice standpoint, it is also the right thing to do for our non-English speaking patients, regardless of whether we achieve the expected outcomes.

Potential unintended consequences include further alienation of some patients who do not speak our most common languages (we only have resources presently to create instructions in 5 languages at this time). Also, it may be that patients accessing their instructions may download the wrong instruction and therefore ideally the staff will make it clear which link to access. The design of the online library has been made as clear as possible, but this is a potential unintended but reversible consequence.

POTENTIAL IMPACT AND SCALABILITY

Ideally, this change can be scaled in many ways. We overall underuse the idea of online discharge instruction libraries, and this idea could be expanded to include post-procedure instructions for many different procedures, both in the clinic and the operating room. It could also include discharge instructions after hospitalization that goes beyond post-procedure care. We will be able to add more languages relatively easily through the translation department as resources are made available (a fee is included for translations).

Additionally, this is a great opportunity to provide better education to our patients in general, outside the context of post-procedure instruction. An online library could include documents targeted to patients on how to care for their urologic disease, information about certain pathologies, instructions on how to self-catheterize, how to change a urostomy bag, how to operate an artificial urinary sphincter or inflatable penile prosthesis, how to empty a Foley bag, definitions of UTI or Peyronies, etc. We have many of these documents already translated to other languages through this same project, and eventually this could become a local and ideally national resource for patients to access with simply a link or a QR code.

SUSTAINING THE CHANGES

Partnering with the clinic staff to implement this into the standard care and workflow for non-English patients has been critical. Posting the QR code for access to online versions will outlast the residents and staff as they turn over, and having nursing and management champions will ensure the longevity of the project through new staff training and onboarding.

REFERENCES

1. Ngai, Ka Ming, et al. "The association between limited English proficiency and unplanned emergency department revisit within 72 hours." Annals of emergency medicine 68.2 (2016): 213-221.
2. Yeheskel, Ariel, and Shail Rawal. "Exploring the ‘patient experience’of individuals with limited English proficiency: A scoping review." Journal of immigrant and minority health 21.4 (2019): 853-878.
3. Ngo-Metzger, Quyen, et al. "Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use." Journal of general internal medicine 22 (2007): 324-330.
4. Jang, Minyoung, et al. "Evaluating the impact of translated written discharge instructions for patients with limited English language proficiency." International Journal of Pediatric Otorhinolaryngology 111 (2018): 75-79.
5. Lo, Shuilain, Diane L. Stuenkel, and Lori Rodriguez. "The impact of diagnosis-specific discharge instructions on patient satisfaction." Journal of PeriAnesthesia Nursing 24.3 (2009): 156-162.
6. Luan-Erfe, Betty M., et al. "Limited English Proficiency and Perioperative Patient-Centered Outcomes: A Systematic Review." Anesthesia & Analgesia (2022): 10-1213.

PROJECT LEAD CONTACT INFORMATION

Max Bowman, MD
University of California, San Francisco (UCSF)
maxbowman3@gmail.com