Evaluation of a Quality Improvement

Intervention to Increase Use of

Telephonic Interpretation
K. Casey Lion, MD, MPHa,b, Beth E. Ebel, MD, MSc, MPHa,b,c,d, Sarah Rafton, MSWc, Chuan Zhou, PhDa,b, Patty Hencz, RNc,
Rita Mangione-Smith, MD, MPHa,b

BACKGROUND: Language barriers are associated with poor health care outcomes, abstract
and barriers exist for timely in-person interpretation. Although available
on-demand, telephonic interpretation remains underutilized. This study
evaluates whether a quality improvement (QI) intervention was associated
with rates of interpretation and parent-reported language service use at
a children’s hospital.
METHODS:The QI intervention was developed by a multidisciplinary team and
included provider education, electronic alerts, standardized dual-handset
telephones, and 1-touch dialing in all hospital rooms. Interpreter use was
tracked for 12 months before, 5 months during, and 12 months after the
intervention. Weekly rates of interpretation per limited English proficient
(LEP) patient-day were evaluated by using segmented linear regression.
LEP parents were surveyed about professional interpretation and delays in a
Department of Pediatrics and dHarborview Injury
Prevention and Research Center, University of Washington,
care. Responses before, during, and after the intervention were compared by Seattle, Washington; bCenter for Child Health, Behavior and
using the x2 test for trend. Development, Seattle Children’s Research Institute, Seattle,
Washington; and cCenter for Diversity and Health Equity,
RESULTS: Telephonic interpretation rates increased by 53% after the Seattle Children’s Hospital, Seattle, Washington
intervention (baseline 0.38 per patient-day, increased 0.20 [0.13–0.28]).
Dr Lion conceptualized and designed the study,
Overall (telephonic and in-person) interpretation increased by 54% performed the analyses, and drafted the
(baseline 0.96, increased by 0.51 [0.38–0.64]). Parent-reported interpreter manuscript; Dr Ebel assisted with study design,
use improved, including more frequent use of professional interpreters participated in analysis planning and interpretation,
and reviewed and critically revised the manuscript;
(53.3% before, 71.8% during, 69.3% after, P trend = .001), less frequent use of Ms Rafton and Ms Hencz contributed to study design
ad hoc interpreters (52.4% before, 38.1% during, 41.4% after, P trend = .03), and reviewed and provided critical input on the
and fewer interpretation-related delays in care (13.3% before, 7.9% during, manuscript; Dr Zhou provided critical input on study
design and analysis, and reviewed and revised the
6.0% after, P trend = .01).
manuscript; Dr Mangione-Smith participated in
CONCLUSIONS:This QI intervention was associated with increased telephonic study design, contributed to analytic planning and
interpreter use and improved parent-reported use of professional language interpretation of results, and critically revised the
manuscript; and all authors approved the final
services. This is a promising approach to deliver safe, timely, and equitable manuscript as submitted.
care for the growing population of LEP children and families. www.pediatrics.org/cgi/doi/10.1542/peds.2014-2024
DOI: 10.1542/peds.2014-2024
Accepted for publication Sep 23, 2014
Increasing numbers of patients and telephonic professional medical
Address correspondence to K. Casey Lion, MD, MPH,
families report having limited English interpretation effectively mitigate
Center for Child Health, Behavior and Development,
proficiency (LEP).1 Language barriers the risks associated with language Seattle Children’s Research Institute, M/S CW8-6, PO
in the health care setting are associated barriers,12–14 but underutilization Box 5371, Seattle, WA 98145-5005. E-mail: casey.lion@
with increased cost,2 decreased of professional interpreters is seattlechildrens.org
satisfaction3,4 and adherence,5,6 widespread.15–19 Many providers PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
variation in testing and diagnosis,2,7 choose to “get by” with nonproficient 1098-4275).
and increased serious adverse language skills,20 and in a 2010 survey, Copyright © 2015 by the American Academy of
events.8–11 Both in-person and 44% of pediatricians who regularly Pediatrics

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PEDIATRICS Volume 135, number 3, March 2015 QUALITY REPORT
saw families with LEP reported using
no professional interpretation.15
The reasons for underuse are
multifactorial and, at the system
level, involve organizational culture,
lack of investment in interpretation,
inconsistent identification of language
need, and inadequate clinician
training.21,22 At the encounter level,
provider decision-making includes
considerations of their own and
the patient’s or family’s language
proficiency, convenience, and the
expected complexity of the clinical
encounter.23–25 Unfortunately,
clinicians do not reliably assess
their own proficiency,24 and a priori
decisions about an encounter’s
complexity necessarily account only
for the clinician’s agenda, not the
family’s. In addition, some families,
not accustomed to being offered
professional interpretation, bring
untrained friends or family members
to interpret. This practice of ad hoc
interpretation, while embraced by
many clinicians for convenience,22
is associated with increased risk
for miscommunication and patient
harm.26–28
Telephonic interpretation is
available on-demand, is less
expensive than in-person
interpretation, and is accessible
in numerous languages. In 2011,
a Rapid Process Improvement
Workshop was conducted at Seattle
Children’s Hospital (SCH) to develop
a multifaceted quality improvement
(QI) intervention with the goal of
increasing inpatient telephonic
interpreter use. The primary
objective was to increase rates of
telephonic interpretation for LEP
families of hospitalized children,
while maintaining or improving
overall interpretation rates.
Secondary objectives were to
decrease parent-reported delays
in care associated with waiting for
an in-person interpreter, and to
improve parent-reported use of
professional interpretation by
medical providers.
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e710
METHODS
Setting
This QI intervention and evaluation
were conducted at SCH, a large
children’s hospital in the Pacific
Northwest. In 2012, 16% of
hospitalized children were from
families with LEP. Fifty-six percent
of those spoke Spanish; the next most
common languages were Somali,
Vietnamese, and Russian. Language
need was assessed at hospital
registration by asking what language
the parents or caregivers prefer for
medical communication. This
registration question replaced the
previous question, regarding primary
language spoken at home, in July
2011, shortly before the QI
intervention. All clinic schedulers
and hospital registration staff were
trained to ask the new question of
all families at every encounter. The
preferred language for care was
recorded in the patient electronic
medical record (EMR). Given that
most individuals who prefer a non-
English language for medical care
have LEP,29 we refer to these families
as LEP in this article. The hospital
employed 21 professional in-person
interpreters and contracted with
agencies for in-person language
services when needed. Telephonic
interpreter services in .100
languages were available in every
hospital room 24 hours per day. Most
rooms were already equipped with
dual handsets and 1-touch dialing.
All interpretation services were
provided at no cost to families.
New physicians and nurses were
instructed in the use of in-person
and telephonic interpreters, with
the stated expectation that all
medical communication occur in
the family’s preferred language.
Provider language proficiency
assessment with a validated program
was being pilot-tested with select
providers beginning in early 2011,
6 months before the intervention. The
program was formally implemented
in October 2012 (toward the end
of the postintervention period)
and included a policy requiring
providers and staff not passing the
language proficiency test to use
professional interpretation for medical
communication. This program and
policy were adopted to comply with
the federal mandate requiring that
institutions ensure the linguistic
competence of those providing
medical care in nonnative languages.30
Previous research has demonstrated
such testing may prevent potentially
dangerous nonproficient clinical
language use.20,31
Despite their availability,
language services at SCH remained
underutilized. From 2010 to
2011, over 40% of LEP patients
received fewer than 2 professional
interpretations per hospital day.
Families with LEP who spoke
languages other than Spanish were
less likely to have access to prompt
in-person interpretation, and had
a nearly 80% lower odds of meeting
that standard compared with
Spanish speakers.
Intervention
The QI intervention was developed
during a 5-day Rapid Process
Improvement Workshop. These
workshops are structured events
conducted through the hospital
Continuous Performance
Improvement Department and
are based upon the Toyota Lean
methodology.32 Multidisciplinary
participant teams map the current
process, identify barriers and
redundancies in the system, develop
an intervention, and plan a rapid
implementation process with specific
evaluation metrics.
The design workshop was conducted
in August 2011, and the intervention
was implemented from August
through December 2011. The
intervention consisted of targeted
education, institution-wide media,
EMR alerts, and telephone equipment
upgrade and standardization
throughout the hospital (Fig 1). The
LION et al

FIGURE 1
Components of the multifaceted QI intervention.
multifaceted approach sought to
educate providers and decrease
barriers to telephonic interpreter
use. Education was delivered by
Interpreter Services staff at division
meetings for physicians, nurses,
residents, and support staff. These
10-minute interactive sessions
emphasized the importance of using
professional interpretation without
delaying care, and demonstrated
access to telephonic interpretation.
During the same period, a series of
articles with the theme “Don’t Wait,
Communicate!” were posted on the
hospital intranet homepage, and
links to the articles were emailed
to all personnel. The articles
highlighted the importance of
using telephonic interpretation to
communicate with LEP families
immediately, rather than delaying
care by waiting for in-person
interpretation. This message was
reinforced with a time-limited alert
in the EMR. Over a 3-month period,
anyone who ordered in-person
interpretation received an alert
recommending the use of telephonic
interpretation for brief or time-
sensitive communications, and
reminding them how to access
telephonic interpretation. Telephone
interpretation equipment and
signage were revamped and
standardized throughout the hospital
to ensure that 1-touch dialing was
clearly marked. An inspection
ensured that dual handsets were
installed and functioning properly
in each room.
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PEDIATRICS Volume 135, number 3, March 2015
Data Collection
The evaluation aimed to determine
the intervention impact on (1) overall
and telephonic interpreter use,
and (2) family-reported receipt of
language services and delays in care.
Data sources are described below
by objective. For analyses, the
preintervention period was August
2010 to July 2011; the intervention
period was August to December
2011; and the postintervention
period was January to December
2012.
Interpreter Use
The analysis included all
interpretations for LEP families
whose children were hospitalized on
a medical or surgical unit between
August 2010 and December 2012.
Interpreter use data were compiled
from orders placed for in-person
interpretation and invoices for
telephonic interpretation. Each
time- and date-stamped interpretation
encounter was linked to the child’s
medical record number. Using
patient admission, discharge, and
location data for LEP children,
we generated weekly reports
measuring professional interpretation
per patient-day, telephonic interpretation
per patient-day, and telephonic
interpretation as a percent of total
interpretation.
Parent-Reported Language Services and
Delays in Care
Parents of hospitalized children were
invited to participate in the National
Research Corporation Picker Family
Experience Survey, completed in-
person or by telephone between
24 hours before and 7 days after
discharge. The survey is routinely
offered to all families being
discharged from the hospital, and is
self-administered or administered by
a research assistant. The Family
Experience Survey was developed
and validated in adult patients,33 then
adapted for and field-tested with
families of hospitalized children.34
The survey was available in multiple
languages and professional
interpretation was used to administer
the survey when needed. In the
survey, caregivers were asked for
their preferred language for
discussing their child’s medical care.
If the response was a non-English
language, several questions about
language services were asked. These
questions included whether an
interpreter (in-person or telephonic)
was always present when discussing
medical care (always, usually,
sometimes, rarely, or never); how
often a family or friend (ad hoc
interpreter) was used to interpret
(always, usually, sometimes, rarely,
or never); and whether care was
ever delayed while waiting for an
interpreter (yes, no, or don’t know).
Analysis
We analyzed temporal changes in
interpreter use with segmented linear
regression, a method of interrupted
time series analysis.35 Segmented
linear regression allowed each time
period to have its own intercept (base
level) and slope (trend), and then
comparisons of differences across
time periods were made by testing
linear combinations of the regression
coefficients. If statistically significant
differences in intercepts and slopes
existed, individual intercepts and
slopes for different time periods
were retained. If no differences in
intercepts and slopes existed,
a more parsimonious model assuming
a common intercept and slope was
subsequently tested. We constructed
e711
separate segmented linear regression
models for each outcome: (1)
telephonic interpretations per patient-
day, (2) overall interpretations per
patient-day, and (3) proportion of
telephonic interpretation. Weekly
averages for each outcome were
used in analyses.
For survey data, responses were
dichotomized for analysis, with the
ideal answer (eg, “always” for
having an interpreter present) coded
as yes, and all other answers as no.
Responses of “don’t know” were
dropped from analysis. Percent of
families providing this “top-box”
response was compiled for each time
period (before, during, and after
intervention). Changes in parent
response over time were evaluated
by using x2 trend analysis for
proportions.
Human Subjects Review
The SCH Institutional Review Board
reviewed and approved the study.
RESULTS
Interpreter Use
Patients with LEP contributed 10 890,
3981, and 9472 patient-days to the
before, during, and after intervention
periods, respectively. There were no
statistically significant within-period
changes in outcomes for any of the
3 models (all slope coefficients
between 20.01 and 0.01, and all
corresponding P . .1), so we
assessed differences in mean values
for each time period by using the
more parsimonious models without
slopes. During the preintervention
period, the average number of
telephonic interpretations per
patient-day was 0.38 (0.33–0.43).
There was no significant change
during the intervention period (0.04;
95% confidence interval [CI]: 20.06
to 0.14), but there was an increase
of 0.2 telephonic interpretations
per patient-day during the
postintervention period (95% CI:
0.13 to 0.28), representing a 53%
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e712
increase over baseline (Fig 2). A
similar pattern was seen in overall
interpretations per patient-day,
representing a 54% increase during
the postintervention period in overall
interpretation (Fig 3). The proportion
of interpretations delivered by
telephone was 0.40 at baseline (95%
CI: 0.37 to 0.43). There was a small,
borderline-significant increase during
the intervention (0.05; 95% CI:
0 to 0.11), but it was not maintained
during the follow-up period (0; 95%
CI: 20.04 to 0.04).
Parent-Reported Language Services
and Delays in Care
Research assistants approached 286
LEP parents before, 149 during, and
290 after the intervention for survey
participation. These represent ∼20%
of the LEP admissions to medical or
surgical units over the study period.
Reasons for nonapproach were
generally related to research assistant
availability, such as weekend or
after-hours discharge and staffing
limitations, rather than patient or
family characteristics. Of those
approached, survey responses were
obtained from 185 LEP parents
before, 117 during, and 203 after
the intervention, for survey response
rates of 65%, 79%, and 70%,
respectively. Compared with baseline,
the proportion of LEP caregivers
reporting that a professional
interpreter was always used for
medical communication increased
significantly during and after the
intervention, from 53.3% to 71.8%
and 69.3%, respectively (P trend =
.001; Table 1). Over the same period,
the proportion of families reporting
ad hoc interpretation by a friend or
family member decreased
significantly, as did the proportion
of families reporting delays in care
due to waiting for an interpreter
(Table 1).
DISCUSSION
In this evaluation of a QI intervention
to improve telephonic interpreter use,
rates of telephonic and overall
interpretation per patient-day
increased significantly after the
intervention and were sustained.
The intervention was associated
with fewer caregiver reports of
interpreter-related delays in care,
decreased use of ad hoc interpreters,
and improved consistency of
professional interpreter use by health
care providers. These significant and
sustained improvements in language
service use during the care of sick
children are likely to decrease
risk for errors and improve the
communication and comprehension
between providers, parents, and
patients.
Although the intervention increased
rates of telephonic interpretation,
we also found increases in overall
interpretation. The lack of change
in telephonic interpretation as
a percent of overall interpretation
suggests that in-person interpretation
increased at a similar rate during
the study period. Our findings suggest
that while efforts to encourage
substitution of remote for in-person
interpretation may not have been
effective, efforts to increase
awareness of the need for
professional interpretation were.
The concurrent increase in in-person
interpretation may stem from the
previously reported finding that
many providers prefer in-person over
telephonic interpretation, especially
for understanding and addressing
cultural nuances and nonverbal
aspects of communication.36,37
And while our intervention was
successful, more improvement is
still needed, because an average of
1.5 interpretations per patient-day
is still below the hospital’s minimum
goal of 2, and well below the number
of times care providers likely enter
the room.
The rapid process improvement
approach aimed to identify and
address multifactorial barriers to
telephonic interpreter use, so that
isolating the impact of individual
LION et al
FIGURE 2
Rate of telephonic interpretation per patient-day over time. Diamonds reveal weekly average rate, and the black line reveals mean rate over each study
time period, annotated with segmented linear regression results.

element(s) of the intervention was single-item interventions,38 so outcomes (percent telephonic

not possible. Multifaceted ultimately it may not be helpful to interpretation, ad hoc interpreter use,
interventions have generally been isolate the impact of individual and professional interpreter use), the
found to be more effective than components. However, among some period of greatest change was noted

FIGURE 3
Rate of total (in-person and telephonic) interpretation per patient-day over time. Diamonds reveal weekly average rate, and the black line reveals mean
rate over each study time period, annotated with segmented linear regression results.

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PEDIATRICS Volume 135, number 3, March 2015 e713
TABLE 1 Parent-Reported Use of Professional Interpreter (In-Person or Telephonic) for Medical Communication, Use of Ad Hoc Interpreter (Family or
Friends), and Delays in Care Before, During, and After the QI Intervention
Before (August 2010–July During (August 2011– After (January 2012– x 2 Test for
2011), % (n/N) December 2011), % (n/N) December 2012), % (n/N) Trend
Professional interpreter always present when 53.3 (98/184) 71.8 (84/117) 69.3 (140/202) P = .001
discussing medical care
Friend or family member ever interpreted 52.4 (97/185) 38.1 (43/113) 41.4 (84/203) P = .03
Care delayed due to waiting for interpreter 13.3 (24/180) 7.9 (9/114) 6.0 (12/200) P = .01

during intervention implementation,
with some attenuation of effect in
the following year, suggesting that the
changes were likely related to the
intervention, rather than a secular
trend related to other factors.
Few studies have evaluated the
impact of QI interventions to
improve the use of professional
interpretation. The original Speaking
Together learning collaborative,
a network of 10 hospitals
constituting the first national
language services QI network (of
which SCH was 1), resulted in
modest improvements in at least
1 language service process metric
per participating hospital, such as
screening for preferred language
for care.39 At another institution,
installation of standard, dual-
handset telephones with easy
interpreter access in every hospital
room improved provider-reported
use of telephone interpretation.40
These interventions demonstrated
improvements in the foundational
aspects of providing high-quality
language services, namely
identifying need and improving
access, which are essential first
steps.
Our QI intervention and evaluation
built upon these successes by
demonstrating an approach for
improving language service
timeliness and use at a hospital with
a robust language access program.
Unlike previous studies, our
evaluation included a full year of
pre- and postimplementation data,
so our conclusions are unlikely to be
attributable to seasonal variation
and demonstrate sustained impact
over time. Incorporation of language
service process and outcome
measures strengthened confidence
in the results, because the
intervention increased the number
of interpretations per patient-day,
and improved parent-reported
experience of language services.
According to the Institute of
Medicine, high quality care should
be timely, patient-centered, and
equitable41; this QI intervention
succeeded in improving the quality
of care delivered to LEP patients and
families.
This study had several limitations.
This was an uncontrolled study, and
the possibility that secular trends or
confounding factors accounted for the
changes in interpreter use and parent
experience cannot be excluded.
However, the inclusion of 1 year of
pre- and postintervention data
decreased the likelihood that findings
resulted from seasonal variation or
short-lived effects. There were 2
additional changes to care for LEP
families during the study time period,
but unrelated to the study, that
deserve mention. The change in
registration question to identify
language need that occurred
immediately preintervention could
have caused the appearance of
improved interpretation rates by
removing non-LEP families from the
denominator. However, if that were
the case, we would expect to see an
immediate, marked change in rates,
rather than the more delayed change
we found. In addition, it would not
have influenced our parent-reported
outcomes, because LEP for those
analyses was determined by a survey
question. The other change was the
rollout of language proficiency testing
for providers. Pilot testing was in
effect for most of the study, making it
unlikely to substantially influence our
findings. The program was officially
implemented in October 2012.
Although interpretation rates were
high in October through November
2012, they were not so high as to
cause a statistically significant change
over time (slope) during the
postintervention period, making it
unlikely that it influenced our results
appreciably. A second limitation is
that measurement of electronic
orders for in-person interpretation
may have under- or overestimated
actual use. At times, an order may
have been placed that was not filled
(eg, no Nepali interpreter available at
the requested time), or the ordering
provider may have cancelled the
request. Alternatively, an in-person
interpreter may have been asked to
interpret for multiple providers (eg,
the nurse and the resident), or may
have interpreted for several patients
with the same provider without
requesting a new order. Providers did
not routinely document use of
professional interpretation, so it was
impossible to validate orders with
documented use. However, the
relationship between orders and
actual interpretations was unlikely
to have changed over time, so
differences over time are likely
accurate. In addition, LEP families
completing the survey may not have
been representative because of low
approach rates, but this lack of
representativeness was consistent
across all 3 study periods. Finally, this
study was conducted at a single
institution with a strong preexisting
commitment to improving care for
LEP patients, which may limit the
generalizability of the specific

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e714 LION et al
intervention to institutions with
similar infrastructure and
organizational culture.
CONCLUSIONS
This multifaceted QI intervention,
developed by using interdisciplinary
stakeholder input and consisting of
education, electronic alerts, hospital-
wide messaging, and equipment
standardization, was associated with
improved rates of telephonic
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by The Robert Wood Johnson Foundation (grant 65127; PI: Dr Ebel), the Center for Diversity and Health Equity at Seattle Children’s Hospital, and
the Department of Continuous Performance Improvement at Seattle Children’s Hospital.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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PEDIATRICS Volume 135, number 3, March 2015
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Evaluation of a Quality Improvement Intervention to Increase Use of Telephonic
Interpretation
K. Casey Lion, Beth E. Ebel, Sarah Rafton, Chuan Zhou, Patty Hencz and Rita
Mangione-Smith
Pediatrics 2015;135;e709
DOI: 10.1542/peds.2014-2024 originally published online February 23, 2015;

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Evaluation of a Quality Improvement Intervention to Increase Use of Telephonic
Interpretation
K. Casey Lion, Beth E. Ebel, Sarah Rafton, Chuan Zhou, Patty Hencz and Rita
Mangione-Smith
Pediatrics 2015;135;e709
DOI: 10.1542/peds.2014-2024 originally published online February 23, 2015;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/135/3/e709

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