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Providing safe and effective care for LEP patients requires that all members of the health care team, including physicians, nurses, interpreters, and frontline staff, work together effectively. Given that team functioning around the care of LEP patients may be suboptimal, one important part of improving care for this vulnerable population is to create a more effective team dynamic that fosters attention to the intersection between language barriers and patient safety.

While the previous chapter describes specific mechanisms to identify, report, monitor, and prevent patient safety issues for LEP patients, this chapter will focus more specifically on team performance and care delivery on the ground. We will describe a new training module that is part of the TeamSTEPPS patient safety system. This tool centers on a set of team behaviors and structured communication tools to improve patient care and reduce medical errors for LEP and culturally diverse patients. Figure 14 presents an overview of the LEP Module.

TeamSTEPPS is presented here as one way a hospital can implement the key processes to improve safety for LEP patients (identify language needs, call for interpreter, empower interpreter to be a member of the care team, address interpreter shortages). However, it is just one tool, and we encourage hospitals to implement the recommendations in this guide any way they can, using any tools at their disposal.

Unlike other team-based trainings, TeamSTEPPS does have several advantages, including that it is evidence based and field tested, comprehensive, customizable, and publicly available at no cost. Most important, it provides easy-to-use teamwork tools and strategies.

Background on TeamSTEPPS and the TeamSTEPPS LEP Module

In November 2006, AHRQ, in collaboration with the Department of Defense, released Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) as the national standard for team training in health care.20 TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals. It includes a comprehensive set of ready-to-use materials and a training curriculum to successfully integrate teamwork principles into any health care system. The approach is scientifically rooted in more than 20 years of research and lessons from the application of teamwork principles.

TeamSTEPPS was originally successfully implemented through military health care and has recently been expanded nationally and implemented at hospitals across the country. There are currently five national implementation centers (Team Resource Centers) nationwide. These centers offer training to create a national network of master trainers, who in turn offer TeamSTEPPS training to frontline providers in hospitals and other health care settings throughout the country. Recent research has shown that TeamSTEPPS is effective in multiple settings at improving care outcomes, team communication, and team attitudes.^21-24

TeamSTEPPS provides higher quality, safer patient care by:

• Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients.
• Increasing team awareness and clarifying team roles and responsibilities.
• Resolving conflicts and improving information sharing.
• Eliminating barriers to quality and safety.

TeamSTEPPS has a three-phase process aimed at creating and sustaining a culture of safety (go to Figure 15 for brief overview). This process includes:

• Pretraining assessment for site readiness.
• Planning, training, and implementation.
• Sustainability.

The three phases of TeamSTEPPS are based on lessons learned, existing master trainer or change agent experience, quality and patient safety literature, and culture change. A successful TeamSTEPPS initiative requires a thorough assessment of the organization and its processes and a carefully developed implementation and sustainability plan. A change team is expected to drive the process within each institution that implements the system.

The change team is typically composed of four to six "change agents" who are respected individuals with the motivation and skills to effect change. As part of the process, each institution sends individuals to a "master training." Master trainers then return to their home institutions to train interprofessional care teams within one or more units of the hospital.

We have used the principles and structure of the TeamSTEPPS approach to develop a TeamSTEPPS LEP Module specifically focused on building a health care team's capacity to improve safety for LEP patients.⁶¹

TeamSTEPPS Module Content: Team Behaviors To Improve LEP Patient Safety

Improving team communication when caring for LEP patients is a complex process, but it can be broken down into some basic components. Based on a review of the literature and findings from our research, we identified several key team behaviors that are central to improving patient safety for LEP and culturally diverse patients (Figure 16). While these do not represent a complete list of issues, they are a useful framework from which to start and are at the core of the TeamSTEPPS LEP Module content. The case example, presented in Appendix B, provides a common miscommunication scenario due to language and highlights potential negative outcomes that would occur if the following steps below were not taken properly.

Identifying Language Needs

Team behavior:

• Front desk staff effectively assess preferred language for health care and need for an interpreter. This may include an assessment of cultural and literacy needs.
• Front desk staff rapidly and effectively communicate patient language, cultural, and literacy needs to the care team.

Calling for Interpreter and Interpreter Present for the Entire Encounter

Team behavior:

• The care team calls a qualified medical interpreter to the encounter for LEP patients. This may include face-to-face, telephone, video, or Web-based interpreters.
• An interpreter is present (either in person or by phone or video) from the beginning of the encounter to its end.

Empowering Interpreter To Be a Member of the Primary Care Team

Team behavior:

• The interpreter uses TeamSTEPPS structured communication tools to bring to the providers' attention conditions that may threaten LEP patients' safety.
• The care team uses TeamSTEPPS structured communication tools to elicit, recognize, and act upon information provided by the interpreter to improve LEP patient safety.
• The care team works with the interpreter to assess patient understanding through the use of the Teach- Back, Teach Me Three (questions that guide Teach-Back ), or similar techniques.

Structured communication tools include:

• Briefs to designate team roles and responsibilities and establish psychological safety and goals for all team members.
• Check-backs to verify that all team members share the same understanding.
• Teach-backs to confirm patient understanding by having patients explain in their own words what they were told.
• CUS words: an agreed-upon communication tool that any team member can use to stop the action at any time when there is any concern for miscommunication or risk to patient safety. The CUS words are Concern ("I am concerned that..." ), Uncomfortable ("I am feeling uncomfortable because..."), and Safety ("This is a safety issue.").

These are described in more detail in Appendix B, Bringing It To Life — A Case Study, which is adapted from the TeamSTEPPS LEP Module.

Addressing Interpreter Shortages

Team behavior:

• Team members raise concerns about interpreter shortages up the management chain.

Summary of TeamSTEPPS LEP Module

The purpose of the TeamSTEPPS LEP Module is to train interprofessional care teams working together in hospital units on the knowledge, attitudes, and team behaviors needed to reduce the number and severity of patient safety events affecting LEP and culturally diverse patients in their unit. The intent is to train doctors, nurses, technicians, front desk staff, and interpreters together so that they will improve their team dynamics.

The module provides facts and statistics regarding the increased patient safety risk to LEP patients and encourages hospitals to provide local data on their LEP patient population and describe existing policies on interpreter services. Hospitals will highlight risks specific to their LEP population and work with unit staff to refine and reinforce their process, roles, and responsibilities in accessing language assistance. The module also provides structured communication tools, such as briefs, check-backs, and teach-backs, to make it easier for staff members and patients to identify and raise patient communication issues. Finally, trainees will learn how to prevent miscommunication by creating a psychologically safe environment for others to clarify misunderstandings.

The TeamSTEPPS LEP Module, which can be used to augment core TeamSTEPPS training or as a standalone training, is an easy-to-use comprehensive multimedia kit that contains:

• "Train the trainer" module.
• Workshop materials, including slides, handouts, and exercises.
• Video vignettes to illustrate key concepts.
• Evaluation guide and metrics.