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Linguistic Support to Improve the Patient Experience
What was the opportunity, issue or challenge you were trying to address and in what setting?
In 2017, Geisinger Holy Spirit’s Associate Chief Medical Officer (ACMO) Dr. Shubhra Kumar-Bradley identified an opportunity to improve the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, specifically in the question; “How often did doctors explain things in a way you could understand” within the Doctor Communication domain. This question is one way to measure the effectiveness of communication physicians have with their respective patients.
Ranking in the first percentile for this question, Dr. Kumar-Bradley established a focus group of hospitalists employed by Geisinger Holy Spirit, to begin to identify a solution to the communication barriers with the patients.
What process did you use to develop a solution?
The focus group was the first step in building a plan to address the problem. A consistent review of the weekly patient’s comments was another step in the process to identify the communication barriers between physicians and patients.
At the time when the focus group was established, there were 27 hospitalists, 25 of whom were English as Second Language (ESL) speakers. Dr. Kumar-Bradley took the time to educate the hospitalists about the questions on the survey. Additionally, she highlighted the patient comments identifying challenges patients perceived in understanding the physicians because of their respective accents.
The focus group of ESL physicians concluded that increasing the fluency of their English would help positively influence the patient experience scores and aide in the connectivity between patients and physicians.
What outcomes were you looking to achieve?
The goal of this effort was three-fold: to increase physician engagement within the Geisinger Holy Spirit inpatient setting, to increase Top Box mean score within Doctor Communication domain, and to decrease the amount of patient comments related to the physician-patient communication barriers.
What specific steps did you take to address the problem?
The support staff of the ACMO began an online search for companies offering linguistic training for ESL physicians. It was important Geisinger Holy Spirit select an organization that also preserved the cultural identity of the staff and was flexible enough to accommodate hospitalist work schedules.
Ultimately, it was Accents International, LLC’s (AccInt) online demonstration to members of the patient experience and leadership teams which solidified it as the best company to deliver this linguistic training to the physicians.
What resources, if any, did you engage – either internally or externally – to address the problem?
In the Fall of 2017, Geisinger Holy Spirit partnered with AccInt to bring a 12-week linguistic class to its physicians in both the inpatient and outpatient setting.
Entitled, Powerful Pronunciation®, the 12-week online course is designed to dissect the complexities of the English language. It is designed to enable physicians for whom English is a second language to speak with clarity, confidence, and ease.
Powerful Pronunciation® minimizes communication barriers while maintaining each physician’s unique cultural identity and teaches the following core competencies of the English language:
- 21 standard vowel sounds
- 26 standard consonant sounds
- Patterns of rhythm
- Stress and intonation
- Voice Projection
- Rate of Speech
Using a live virtual classroom with two-way interactive video conferencing, 13 Geisinger Holy Spirit physicians (10 hospitalists and three outpatient physicians) were divided into two cohorts, which met bi-weekly on Tuesday evenings at 9 p.m. (EST) for one hour.
The program components include:
- Initial and Final Assessments that demonstrate the learner’s progress metric, using individual voice recording from each provider
- Individual learning plans, based on the results of the Initial Assessment, identify each participant’s needs and outlines his/her path to success
- Customized Practice Guides after each session summarize instructional content as well as include the pronunciation of each participant’s requested words and/or healthcare related terminology. Each practice guide includes an MP3 recording.
- Individual long-term practice plans, based on the results of the Final Assessment, for carryover of skill acquisition and continued improvement
- Online proprietary learning materials, “American Pronunciation: Core Techniques for Success", hosted in the Cloud and easily accessible on any mobile device, “AP Online” is an audiovisual library of articulation techniques for the sounds in English that do not occur in other languages.
What measures did you establish to determine the success of this effort
Accents International used a phonological assessment tool to measure the errors in the fluency of the physician’s English pronunciation.
Geisinger Holy Spirit used the rate of the “Always” on the HCAHPs survey questions, “Doctors Explained Things in a Way I Understand” of the 10 hospitalists as it its primary measurement of efficacy of the program. Additionally, it did track the mean score of the question, “Degree to which care provider talked with you using words you could understand” on the Medical Practice for the three-participating outpatient physicians.
Feedback and level of engagement of the physicians was assessed by collecting periodic check-ins at staff meetings and individual one-on-one meetings with the physicians throughout the program and beyond.
What was the ultimate outcome of your effort?
Geisinger Holy Spirit met its three stated goals to: increase physician engagement within the Geisinger Holy Spirit inpatient setting, to increase the Top Box mean score within the Doctor Communication domain, and to decrease the amount of patient comments related to the physician-patient communication barriers.
- The confidence of these physicians has significantly increased when communicating with their respective patients. The linguistic support has positively impacted the patient experience scores. Additionally, the gains were sustainable because of ongoing monitoring and weekly access to linguistic support. Of the 13 participating physicians, 11 are still employed with the system; two leaving for advanced leadership positions.
- The rate of the “Always” response for the 10 participating hospitalists increased from 59.4 to 65.5* mean Top Box score. This was measured over a sustained period of eight quarters. *At the time of publication
- Significant reduction in patient comments regarding language barriers over the past 12 months. Reduction in the number of times physicians are asked to repeat themselves to the patients and increased ability for the individual physician to self-correct pronunciation.
Additionally, Accents International, LLC reported a significant increase in the fluency of the English language for 13 participating physicians from Geisinger Holy Spirit by 81.1%.
What lessons did you learn you would share with others as they consider addressing a similar issue?
Developing appropriate and culturally inclusive messaging around this program is one of the key tactics to its success. It is a program designed for ESL physicians and/or providers to develop their fluency of the English language. The focus of this program is on pronunciation, an area of fluency that is seldom taught yet necessary for effective communication in every language. The program gives participants tools to pronounce the sounds in English that do not exist in other languages. Powerful Pronunciation® is not to be confused and/or considered to be an accent reduction program. At program completion, providers maintain their culturally and linguistically rich accent. What’s absent is a significant barrier to fluency and provider-patient connectivity.
Voluntary participation and flexibility of offering classes based on physician schedule are essential to ensuring a successful outcome. The physicians at Geisinger Holy Spirit were highly motivated to participate in this effort because they believed it would help them to improve their confidence, connectivity and communication skills when interacting with their patients. Their collective determination was an integral aspect to the success of their increased fluency and reduction of errors in pronunciation.
Ensuring a technology check of the participating physician’s computer prior to the start of the first session, will enable a smooth start to the program. We found many of the participants were not as familiar with the online technology of a virtual classroom. Establishing a dry-run of the session will ensure the physicians are able to fully participate in the first of the 12 classes.
Finally, continuous monitoring of the patient satisfaction scores helped AccInt establish a 30-minute weekly enhancement session for the graduates of Geisinger Holy Spirit’s Powerful Pronunciation® program. The patient experience director at Geisinger Holy Spirit noted a slight decrease in the rate of “Always” after a sustained period of time. AccInt decided it was essential to create an opportunity for the graduates to continue to have a space to collectively practice their newly acquired skills to help with the sustained gains in patient satisfaction.
About Geisinger Holy Spirit
In 1963, Holy Spirit Hospital opened its doors. It has since grown into a comprehensive health system with locations throughout the greater Harrisburg area, including a 307-bed hospital located in Camp Hill, PA.
In 2014, Holy Spirit Health System affiliated with Geisinger. Since then, Geisinger Holy Spirit (GHS) broadened its services to provide patients with greater access to primary, specialty and advanced care close to home. Recently, GHS has added important services such as advanced bariatric surgery, dermatology, infectious diseases, neurosurgery, orthopedics, plastic surgery, pulmonary medicine and surgical oncology. It has also invested heavily in advanced technology.
Geisinger Holy Spirit is a Pennsylvania Trauma Systems Foundation accredited Level II Trauma Center, providing around-the-clock complex critical care for patients suffering from life-threatening injuries such as those resulting from motor vehicle accidents, falls and acts of violence.
As it has from the beginning, GHS continues to be sponsored by the Sisters of Christian Charity and adheres to the Ethical and Religious Directives for Catholic Health Care Services. As a fully integrated member of Geisinger, it provides a comprehensive array of both inpatient and outpatient services across south-central Pennsylvania and is focused on improving the health and wellbeing of the communities it serves.
Case Study Authored by:
Gretchen L. Ramsey, MPS, Director, Patient Experience, Geisinger Holy Spirit
Shubhra Kumar-Bradley, MD, Associate Chief Medical Officer, Geisinger Holy Spirit
Judy Ravin, President and Founder, Accents International, LLC