Striving to Create a Welcoming Environment for Limited English Proficiency Clients

I. Describe how the specific QI methods and tools were used. Between January 2013 and August 2013, six QI team meetings were conducted. The QI team was made up of 12 members representing different divisions within HCHD. Following is an outline of the tools that were used over the course of these meetings: • Flowcharting: At meeting 1, the QI team was taught the basics of QI, including flowcharting. The goal of the project was to address the lack of use of translation services, specifically phone translation services. A process map was created to visually represent how staff currently used this service. Each program was tasked with creating a flowchart for its individual program (with the help of its staff), and staff submitted these flowcharts in advance via e-mail in preparation for meeting 2. The flowcharts submitted were then compiled to build a basic map of the current state. This process was tested, and the final version was proposed to, reviewed by, and approved by the QI team. This process became standard for the organization going forward. • Process issues chart: At meeting 2, the QI team was led through a discussion to identify all existing process issues around the use of phone translation services. A chart was created, which put these issues into the following categories: process, people, information, equipment, material, and environment. Team members were sent the compiled list between meetings and asked to obtain additional input from the rest of their staff. At meeting 3, the QI team was led through a 2x2 prioritization analysis of all identified issues. The prioritization analysis required staff to plot on a matrix which of these issues happen most frequently and which would have the greatest impact on the project. The group voted on the top four issues, which were among the highest prioritized issues; these landed in the top right quadrant of the matrix. • Cause and effect analysis (5-Whys): Also at meeting 3, the top four issues identified through the prioritization process were taken through a cause and effect analysis. The question "why" was asked many times to try to get at the most basic underlying issue (the root cause). The group then reviewed the root causes, which were identified, and agreed that if these issues were addressed, they would make an impact on the overall problem being solved for: lack of use of translation services. • Solution and effect analysis: At meeting 4, the group was guided through a discussion to identify potential solutions for the root causes. A number of solutions were brainstormed, then put through a 2x2 prioritization matrix, this time considering how great of an impact the solution would have on eliminating the problem and how timely and cost efficient the solution is to implement. The team voted on the solutions that were highest prioritized (those in the top right quadrant). These solutions were then used to develop an improvement theory. II. Describe the initiative itself: why it was chosen, what was to be done initially, and by whom. This project was particularly important as HCHD is interested in establishing a QI framework and team that could continually address issues as they arise. This QI initiative complements HCHD’s application for accreditation to the Public Health Accreditation Board (PHAB). At the same time, HCHD received a Robert Wood Johnson Foundation grant to support its development of a QI infrastructure. The grant would provide 15 hours of coaching by a QI expert, who was provided in tandem with this first QI project: improving communication with LEP clients. The specific topic of LEP was chosen based on data that demonstrated a disconnect between the number of local residents who may not speak English well and those that HCHD serves. The broader priority was to improve outreach and services for minority populations to address health disparities. The deputy health officer proposed and initiated the project by obtaining grant funding and identifying a QI team leader, one of the agency’s health policy analysts. The QI team leader, supported by two additional staff members, spearheaded the QI project, first attending a 5-day QI train-the-trainer session at the Maryland Department of Health and Mental Hygiene (DHMH) and then assembling a QI team, which they guided through a Plan, Do, Check, Act (PDCA) process. III. Describe how the initiative was implemented, including where and when it took place and how it addressed the problem. The initiative was implemented at HCHD's main administrative building in Bel Air, Maryland, over the course of 8 months. Twelve staff members made up the QI team and represented HCHD's different divisions. By engaging in a PDCA process, the QI team was able to identify and propose solutions to senior leadership. The solutions could potentially make a difference in how HCHD serves individuals who speak other languages. IV. Describe who and how many people were exposed to the initiative. These people could be clients, employees, or community members. A total of 144 HCHD staff members were trained on how to use translation services. A brochure insert, announcing the availability of translation services, was distributed to 250 members of the community. In addition, translation services were offered a total of 129 times to clients between June 2013 and July 2013.

To determine whether the project had an impact on improved communication with LEP clients, HCHD had to first determine its baseline. This goal was accomplished by looking at billing data that showed the number of times HCHD was billed for the different methods of translation. Each division also submitted data collected from translation logs that were used to capture encounters with LEP clients. In addition, pre- and post-tests were conducted as part of the translation services training given to staff. The purpose of this evaluation was to determine the percentage of staff trained who had a higher knowledge of how to use translation services, compared with knowledge that staff possessed before receiving the training.