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Team STEPPS: Enhance Safety for Patients with Limited English Proficiency

TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and 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.[1]

In September of 2012, the Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) rolled out a TeamSTEPPS module aimed specifically at improving safety for LEP patients.  Our objective with this post is to introduce the TeamSTEPPS Enhancing Safety for Patients with Limited English Proficiency module to our clients through a conversation with its creator, Cindy Brach[2].  We hope that her description of the LEP module will encourage you to learn more and consider whether it might be of value to your organization.

Q. Why was it important to develop a TeamSTEPPS module specifically for working with limited English proficient patients?

I am AHRQ’s lead for health literacy and cultural competence. I started with the idea: ‘What do we need to do to improve safety for patients with limited English proficiency in hospitals?’  That issue arose because some data indicate that LEP patients are more likely to suffer harm when adverse events occur, and the harm is more likely to be severe.  We also know that communication issues are responsible for a large proportion of adverse events. It became clear that we really needed some training in the hospital around these issues.  Once we came to that conclusion, I naturally turned to TeamSTEPPS as a framework because we already have a great hospital training program that could be built upon to meet the needs of this population.

Q.  Can you talk a bit about how the LEP module builds on the TeamSTEPPS framework?

We wanted to be able to answer the question: ‘How do we make sure our LEP patients are going to be as safe as everyone else?’  TeamSTEPPS has traditionally concentrated on provider to provider communication, how do we function as a team?  We asked: ‘What are the ramifications of having patients with language barriers to functioning as a team and conducting safe interventions?’ The structure of the LEP module is the same as the other skills-based safety training in TeamSTEPPS except one of the people that needs to be a member of your team is the interpreter and we focus on this.

Q.  So in response to LEP safety concerns, AHRQ commissioned two products, the TeamSTEPPS LEP module and Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals.How do they add value to each other?

The Guide is focused more on the reporting of errors, the fact there are barriers to monitoring errors for LEP patients, and that interpreters can be an important resource in reporting errors.  Reporting any adverse event or near miss and figuring out why it happened and trying to address the root causes is at the heart of patient safety.  In the training module, we really adhered to the TeamSTEPPS basic principle of team communication, but we focused on incorporating the interpreter.  For example, CUS is a progressive intervention strategy that stands for ‘I’m concerned; I’m uncomfortable; this is a safety issue, stop, we need to resolve this.’  The LEP module focuses on empowering interpreters to be able to use these types of structured communication strategies and skills.

Q. What are some of the returns you’ve seen hospitals realize after using the LEP module?

We tested the module in three different settings.  What we found is that implementing the module had a ripple effect on policy.  One hospital realized they needed more interpreters in some areas and reorganized and reallocated resources.  In another hospital, they discovered that providers were reluctant to use telephone interpreters because they felt it was disloyal to the interpreter staff.  They would either wait causing delays or else they would start without an interpreter.  Once the hospital realized this was happening, the language services department was able to very clearly communicate that the first thing you do is get interpreter services on the telephone.  They were able to reinforce that the most important thing is to have a qualified interpreter involved throughout the whole duration of the interaction. Another hospital decided that it should certify that bilingual providers were really qualified to deliver care in another language. They wanted to stop providers from trying to “get by” with inadequate language skills.

The module also made them realize that their information systems weren’t adequate to track the type of information they needed to evaluate the impact of conducting the training.  At best they had data on who got interpreter services, but they didn’t have data on patients with LEP who didn’t get interpreter services.   So it was impossible to measure the impact of implementing the LEP module on overall use of qualified interpreters.  We do know, however, that the module increased trainees’ knowledge about providing care to patients with LEP safely. All the hospitals had different goals and were using the module in different ways, but doing the module really helped them think about their policies.

To learn more about TeamSTEPPS go to:

To access the LEP module go to:

To access Improving Patient Safety Systems for Patients With Limited English Proficiency:  A Guide for Hospitals go to:

[1] “TeamSTEPPS®: National Implementation.”  Agency for Healthcare Research and Quality. <>

[2] Cindy Brach, Senior Health Policy Researcher, AHRQ.

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