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“First contact”: use of a language tool to increase rapport, trust and outcomes

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“First contact”: use of a language tool to increase rapport, trust and outcomes

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LANGUAGE TOOL RAPPORT AND TRUST

“FIRST CONTACT”: USE OF A LANGUAGE TOOL TO INCREASE RAPPORT, TRUST,
AND OUTCOMES

by

Athena Bernas

A Doctoral Capstone Proposal Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2024
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The following manuscript was contributed to in equal parts by Athena Bernas, Justin
Humphreys, and Heidi Machen
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Dedication
We want to dedicate this manuscript to our families – we cannot thank you enough.
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Acknowledgments
We would specifically like to thank Drs. Jeffrey Darna, Elizabeth Bamgbose, Amanda
Goodrich, and Justyne Decker, for their support and guidance through this process – your help
was invaluable.

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Table of Contents
Dedication ...................................................................................................................................... iii
Acknowledgments .......................................................................................................................... iv
Abstract .......................................................................................................................................... vii
Chapter 1 ......................................................................................................................................... 1
Introduction ......................................................................................................................... 1
Background and Significance .............................................................................................. 1
Research Question, Project Purpose, and Specific Aims .................................................... 4
Operational Definitions ....................................................................................................... 5
Project Impact ...................................................................................................................... 6
Conclusion ........................................................................................................................... 6
Chapter 2 ......................................................................................................................................... 8
Literature Review ................................................................................................................ 8
Search Strategy ................................................................................................ 8
Language Concordance and Rapport ................................................................................... 9
Language Concordance and Trust ..................................................................................... 10
Language Concordance and Patient Outcomes ................................................................. 12
Conclusion ......................................................................................................................... 16
Chapter 3 ....................................................................................................................................... 17
Methodology ...................................................................................................................... 17
Project Design ................................................................................................................... 17
Communication Tool Development .................................................................................. 18
Setting ................................................................................................................................ 19
Project Population ............................................................................................................. 20
Exclusion Criteria .............................................................................................................. 20
Project Surveys .................................................................................................................. 20
Provider Sociodemographic Data Survey ..................................................... 20
Preintervention Survey .................................................................................. 21
Postintervention Survey ................................................................................. 22
Protection of Human Subjects ........................................................................................... 22
Project Protocol ................................................................................................................. 22
Data Analysis ..................................................................................................................... 23
Chapter 4 ....................................................................................................................................... 24
Results ............................................................................................................................... 24
Baseline and Preintervention Survey Data .................................................... 24
POC Participant Sociodemographic Data ................................................................. 24
POC Provider Satisfaction with the Existing Communication Model ...................... 25
Simple Novel Communication Tool .......................................................................... 25
Multi-language Tool Implementation ........................................................................ 26
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Communication Tool Utility and Effectiveness ........................................................ 26
Chapter 5 ....................................................................................................................................... 28
Discussion.......................................................................................................................... 28
Specific Aims .................................................................................................................... 28
Specific Aim One .......................................................................................... 28
Specific Aim Two .......................................................................................... 29
Specific Aim Three ........................................................................................ 31
Specific Aim Four ......................................................................................... 32
Project Strengths ............................................................................................ 33
Project Limitations ........................................................................................ 34
Recommendations and Future Research ....................................................... 35
Conclusion ......................................................................................................................... 36
References ..................................................................................................................................... 38
Tables ............................................................................................................................................ 45
Figures ........................................................................................................................................... 47
Appendix A ................................................................................................................................... 48
Appendix B .................................................................................................................................... 50
Appendix C .................................................................................................................................... 52
Appendix D ................................................................................................................................... 53
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Abstract
Cultural competence is a set of congruent behaviors, attitudes, and policies that enable
systems, agencies, or professionals to work effectively in cross-cultural situations. In healthcare,
cultural competence refers to the abilities of practitioners and systems to adequately integrate
information about a patient’s unique values, beliefs, and behaviors and tailor their care delivery
to meet specific social, cultural, and linguistic needs. The United States (US) Department of
Health and Human Services (HHS) has acknowledged the importance of linguistically sensitive
care and, in 2000, codified the national standards for Culturally and Linguistically Appropriate
Services (CLAS). Following a comprehensive literature review and the generation of several best
practice recommendations, the authors of this scholarship project created an educational model
and written language tool. The educational tool was disseminated amongst preoperative clinic
staff at a tertiary academic medical center in Southern California. Staff satisfaction surveys were
issued pre- and post-intervention; staff satisfaction scores improved after introducing the
communication tool. A simple communication tool can be quickly and effectively implemented
to facilitate trust, rapport, and visit outcomes during an initial visit with non-English speaking
patients in a preoperative clinic setting
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Chapter 1
Introduction
Despite having long been considered a cultural melting pot, the US is now more
culturally and racially diverse than ever (Budiman, 2020). According to the United States Census
Bureau (2021), race and ethnicity data collected from the 2020 census demonstrated that if two
people were chosen at random from the US population, there would be a 61.1% chance the
individuals would have a different racial makeup, an increase from 54.9% in 2010. These
demographic shifts are also represented in the healthcare sector; as a result, research on cultural
competence in healthcare has increased dramatically in the past 20 years (Saha et al., 2008).
Language is a critical component of cultural background (Centers for Disease Control
and Prevention, 2021). The patient-provider relationship, care access, and satisfaction are
improved when patients and providers speak the same language (Lor & Martinez, 2020).
Furthermore, when practitioners can converse with patients in the patient’s preferred language,
patients feel more comfortable and have increased feelings of trust in their providers (Ali &
Johnson, 2017; Ko et al., 2016). Even when patients and providers do not speak the same
language, patients report increased respect and trust building when providers attempt to
communicate in the patient’s native language (Zamudio et al., 2017).
Background and Significance
Cross et al. (1989) defined cultural competence as a set of congruent behaviors, attitudes,
and policies that enable professionals to work effectively in cross-cultural situations. This
definition has been expanded and adapted to numerous social and organizational environments.
However, in the healthcare field specifically, cultural competence refers to the ability of
practitioners and systems to adequately integrate information about a patient’s unique values,
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beliefs, and behaviors and tailor their care delivery to meet specific social, cultural, and linguistic
needs (Betancourt et al., 2002). Culturally competent healthcare delivery organizations provide
their consumers (patients) with effective, understandable, and respectful care congruent with
their values and beliefs and delivered in a language they can understand (Purnell & Fenkl, 2020).
The importance of adequate communication to culturally competent care cannot be understated;
providing services in a language that patients understand can improve access to care, quality of
care, and health outcomes (HHS, 2001).
Conversely, poor communication has been linked to substandard care and adverse patient
outcomes and is associated with negative experiences and care outside of best practices (Zamor
et al., 2020). Furthermore, Andreae et al. (2017) and Kaufman et al. (2019) reported that poor
communication can increase patient morbidity and mortality.
Poor communication and language discordant care are also linked to diminished trust
within the patient-provider dyad (Molina &. Kasper, 2019). Fields et al. (2016) found that
Spanish-speaking patients had lower trust in English-speaking preoperative clinic (POC)
providers than English-speaking patients. Adequate patient-provider communication improves
trust and rapport, reduces patient anxiety, and can engender feelings of relief and gratitude, all
important to building mutually beneficial therapeutic relationships (Molina &. Kasper, 2019).
In 2000, HHS acknowledged that poor communication contributed to poor patient
outcomes and needed improvement in overall quality and effectiveness. Subsequently, HHS
drafted and released the National Standards for Culturally and Linguistically Appropriate
Services (CLAS) in health and healthcare (HHS, 2001). The CLAS Standards promote effective
communication regarding diverse cultural health beliefs, health literacy, and preferred language
while complying with the Title VI Civil Rights Act of 1964 and the Americans with Disabilities
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Act of 1990. Their adoption has been codified within the Centers for Medicare & Medicaid
Services (CMS) regulations, and federally funded institutions mandate 4 of the 15 standards.
Such institutions include, but are not limited to, hospitals, nursing homes, home health agencies,
managed care organizations, universities or other entities with health/social research programs,
state Medicaid agencies, state/county/local health welfare agencies, programs for
families/youth/children (e.g., Head Start programs), public and private health vendors, and any
other program that receives financial assistance from HHS (HHS, n.d.). Standards 4 to 7
specifically emphasize language access services. They require cultural and linguistic care
education for leadership and staff education, no-cost language and translation services for
patients accessing health care, explicit notification of access to written and verbal translation
services in their preferred language, and translator competence. As noted above, adherence to
these four standards is required for all institutions receiving CMS reimbursement.
POCs have evolved over the last thirty years with a focus on patient optimization, risk
mitigation, and perioperative efficiency (Edwards & Slawski, 2016). All federal CMS-funded
recipients must comply with the CLAS standards, including the index POC where this project
was implemented. The index POC for this project has 22 staff members (clinical and non-clinical
staff) with approximately 40 patient visits per day. Nearly a quarter of patients require translation
services during their preoperative visit (J. Decker, personal communication, November 7, 2022).
All front-office staff were fluent in Spanish, and the remainder of the clinic staff spoke English
exclusively or were fluent in another language (e.g., Mandarin, Tagalog, Japanese, etc).
Language discordance between patients and providers was frequent at the index POC and
required regular utilization of interpretation and translation services.
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When language discordance occurs during preoperative interviews, the POC providers
utilize video remote interpretation (VRI) translation services to gather patient data. VRI services
harness videophone technology to connect patients and providers with on-demand, trained
interpreters. These interpretation resources are crucial in POCs as they help ensure accurate data
collection. Diamond (2019) found that patients benefit from and appreciate these high-quality
interpretation services. However, language discordance and miscommunication can still arise
during initial patient-provider interaction and initiation of VRI services. Based on the evidence
supporting language concordance during the initial contact, engaging non-English speaking
patients in their preferred language at the first patient-provider interaction would improve
rapport, trust, and, potentially, patient outcomes.
Research Question, Project Purpose, and Specific Aims
The research question that guided this quality improvement (QI) project was: During the
initial contact with exclusively Spanish, Armenian, Cantonese, and Mandarin-speaking patients,
do POC providers find a simple, phonetically spelled, multi-language communication tool useful
in facilitating patient rapport, trust, and visit outcomes?
The purpose of this QI project was to improve communication during the first contact
between POC providers and patients who primarily spoke Spanish, Armenian, Cantonese, and
Mandarin using a simple, phonetically spelled, multi-language communication tool. The QI
project had four interrelated specific aims.
Specific Aims

1. To determine the POC provider’s satisfaction with initial communication with
Spanish, Armenian, Cantonese, and Mandarin-speaking patients.
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2. To develop a simple, phonetically spelled, multi-language communication tool for
POC providers to greet Spanish, Armenian, Cantonese, and Mandarin-speaking
patients and call them to the back medical office.
3. To implement the multi-language tool for English-speaking providers in the POC at a
major academic healthcare system in Southern California.
4. To measure POC provider satisfaction regarding the utility and effectiveness of the
multi-language communication tool at improving trust, rapport, and visit outcomes.
Operational Definitions
The scholarship project adopted operational definitions to describe the explored variables
of interest:
1. Communication was defined as the ability to adequately exchange information via
speaking, writing, or body language (Merriam-Webster, n.d.a.). For the purposes of
this project, poor communication was defined as its inverse: the inability to
adequately exchange information via speaking, writing, or body language.
2. A historical definition for patient rapport was adopted and defined as a ‘harmonious
relationship’ between the healthcare provider and patient (Spink, 1987).
3. Trust was defined as the belief that someone is reliable, good, honest, and effective
(Merriam-Webster, n.d.b.).
4. No standard definition for ‘patient outcomes’ exists across the healthcare literature.
Generally, the phraseology ‘patient outcomes’ includes multiple objective and
subjective criteria (including, among others, patient morbidity and mortality,
satisfaction, and comfort). Furthermore, the term can be conceptually altered to suit
the aims of an examining researcher (Liu et al., 2014). For this project, outcomes
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were defined as a clinical endpoint affected by a patient’s functional status, safety,
and/or satisfaction.
5. Language proficiency was defined as the ability to interpret effectively, accurately,
and impartially, both receptively and vocally, between two disparate languages
(Jacobs et al., 2018).
6. Language discordance was defined as an instance or interaction wherein the patient
and healthcare provider do not speak the same language (Molina & Kasper, 2019).
7. Quality Improvement was defined as using data to monitor the outcomes of care
processes and using improvement methods to design and test changes to continuously
improve the quality and safety of healthcare systems (QSEN, 2007).
Project Impact
We hypothesized that implementing a simple communication tool at the point of first
contact would increase provider satisfaction in facilitating patient rapport, trust, and visit
outcomes with non-English speaking patients. The QI team designed and implemented a multi-
language tool to bridge the language-discordant communication gaps between patient and
provider. The utility and effectiveness of the language tool were assessed, and recommendations
for future practice were developed.
Conclusion
Language is a critical component of culture. Research shows that patient outcomes
improve when patients and providers speak the same language. VRI or other interpreter services
can facilitate culturally sensitive communication without patient and provider language
concordance; however, attempts at communication upon first contact with patients, before
initiation of VRI or other services can be arranged, has the potential to create mistrust, discord,
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and poor patient outcomes as providers resort to rudimentary gestures and/or inadequate ad hoc
translations. We predicted that POC providers would be satisfied with a simple, phonetically
spelled, multi-language tool during their initial patient encounter with patients who primarily
speak Spanish, Armenian, Cantonese, and Mandarin, and the communication tool would
facilitate patient rapport, trust, and visit outcomes.
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Chapter 2
Literature Review
In order to aid communication during the initial contact between POC providers and
language-discordant patients, we conducted a literature review exploring evidence of language
concordance in facilitating rapport, trust, and improved visit outcomes. We tailored the literature
review to reflect the project’s specific aims. We focused primarily on those articles that
discussed patient and provider satisfaction with patient contact and how patient outcomes are
impacted by patient/provider language concordance.

Search Strategy
We collected data via an online search of PubMed and Google Scholar using the
following keywords/phrases: “health disparities,” “language barriers,” and “language
concordance.” The search generated 959 articles for potential review. We applied the following
inclusion criteria: articles written within the past ten years, full-text availability, peer-reviewed
publications, and English language availability. We excluded duplicates and non-healthcare-
specific (e.g., education or legal-focused) articles. After applying these criteria, 19 articles were
identified for literature review. After identifying these articles, we used a snowball technique and
pursued primary sources, leading to 24 additional sources for review. We selected 34 articles for
review based on subject relevance. We appraised these articles for content quality and research
strength with appropriate appraisal tools (i.e., STROBE checklist). We settled any disagreements
through discussion and consensus.

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Language Concordance and Rapport
In a two-year, retrospective, cross-sectional analysis, Andreae et al. (2017) found that
language-concordant phone calls helped establish rapport before an in-person medical encounter.
The researchers collected appointment attendance data retrospectively from 3,035 initial visits,
15% of which were for Spanish-speaking patients. A logistic regression analysis uncovered that
Spanish-speaking patients who received appointment reminders in their preferred language
before their initial visit were more likely to adhere to their appointments compared to other
Spanish-speaking groups who received an appointment reminder in English (Adjusted OR =
1.32; 95% CI [1.06-1.64]). The authors credit the initial, linguistically concordant contact with
patients for improving subsequent appointment adherence; they posit that the initial extension of
language-concordant care implied someone would be available during in-person visits to
facilitate communication and address patients’ specific needs.
Patient perception of language barriers can negatively influence patient-provider
relationships. Steinberg et al. (2016) studied the perspectives of Spanish-speaking mothers as
they moved through the healthcare system using semi-structured interviews. The authors focused
on mothers whose children had access to and utilized pediatric primary care services in the year
prior and found that language barriers emerged as the central theme in the mothers’ experience.
Specific themes reported by the participants and identified by the authors included: the ‘battle’ of
managing language barriers, preferring bilingual providers, negative bias towards interpreted
encounters, commonly having to ‘get by’ on limited language skills, feeling like a burden, and
perceived discrimination due to language barriers. Interestingly, the participants who expressed
negative opinions towards interpreted encounters did not have a negative encounter. Instead, past
experiences of poor or inadequate interpretation (e.g., the use of ‘ad hoc’ interpreters or family
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members) led to hesitancy to use interpreters in the healthcare environment. In order to mitigate
some of the themes mentioned above, the authors recommended partnering with patients in a
language of their choosing - starting with their first encounter with the healthcare system.
Aviera (1996) found that practitioners' use of dichos (Spanish language idioms) improved
patient rapport, decreased defensiveness, and enhanced therapy motivation and participation
among Spanish-speaking Latinos seeking mental health services. Aviera compiled observational
data over three years via discussion groups of 5-10 participants aged 18-65 of monolingual,
Spanish-speaking patients. The discussion groups were conducted in a 600-bed psychiatric
hospital in acute and long-term treatment units. The researcher reported that the use of Spanish
language dichos helped build rapport secondary to the cultural depth they were able to convey in
a short period; dichos were culturally meaningful to patients and, as such, were effective at
bridging gaps between patients and providers and proved effective at conveying a sense of care
between providers and patients. The case series acknowledged that using dichos might help
practitioners effectively demonstrate cultural empathy, thereby improving patient engagement.
Language Concordance and Trust
In a prospective, dual-aim, cross-sectional study, Fields et al. (2016) interviewed and
surveyed 475 parents of children who needed emergency care and asked them to quantify their
trust and mistrust in their providers. Parents self-identified as either White, African-American, or
Hispanic, of which 88% identified as English- speaking while 12% identified as Spanish-
speaking. Concurrently, the authors assessed the outcomes of children in English and Spanish-
speaking families to assess if there were discrepancies in specific treatments received. Trust was
assessed using the Pediatric Trust in Physician Scale (Pedi-TIPS), an 11-item, Likert scale
instrument with a high internal consistency (Cronbach α = 0.90), test-retest reliability, and
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construct validity. The level of medical mistrust, described in this case as a perceived treatment
difference between the interviewed group and a comparison group, was measured via the Group
Based Medical Mistrust Scale (GBMMS) (Cronbach α = 0.83). The authors hypothesized that
because of known racial disparities in healthcare access, utilization, quality and outcomes, trust,
and mistrust scores might vary between White and non-White groups. A statistically significant
difference was found in the level of trust in providers between English and Spanish-speaking
parents, with levels of trust being significantly lower among Spanish speakers. The Pedi-TIPS
has a maximum score of 55 to signify trust in children’s physicians, with results showing a
Spanish-speaking mean of 38.16 and English-speaking parents with a mean score of 42.39 (p <
0.0001). Higher mistrust scores were found among Spanish-speaking versus English-speaking
parents via the GBMMS, with a maximum mistrust score of 60. Spanish-speaking parents had a
mean score of 26.75, while English-speaking parents reported a mean of 25.30, although this
difference was not statistically significant (p = 0.1605). English-speaking patients had improved
outcomes in five of seven measured variables (e.g., nebulized medications, IV medications, labs,
imaging studies, and admission status). However, no significant differences were noted between
the two groups. The raw data indicated a difference in X-ray acquisition was 21.96% in English-
speaking versus 3.41% in Spanish-speaking children (p = 0.628). Likewise, admissions data
varied widely, with 9.09% of children in English-speaking families admitted for further care
compared to 0.93% for children in Spanish-speaking families. The authors acknowledged that
the study was not designed to prove a cause-and-effect relationship regarding trust and mistrust.
Interestingly, the increased interventions did not lead to improved care. Due to disparities in
healthcare access, Spanish-speaking families could have used ED services for less severe issues.
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Language Concordance and Patient Outcomes
Zamor et al. (2020) studied the differences in pediatric bronchiolitis management
between English and Spanish-speaking families over seven years. Data collection included
sociodemographic information (e.g., age, race, ethnicity, and insurance status), vital signs, and
diagnostic test results (chest x-ray, complete blood count (CBC), electrolytes, blood cultures,
viral assays, etc.). The researchers analyzed the data from 13,612 infants under the age of 2 years
old who were diagnosed with bronchiolitis during the seven-year study period and inferred
Spanish was the patient/caretaker's primary language if the Electronic Health Record (EHR)
showed a request for Spanish interpreter services. Most encounters (96.8%) were classified as
English-speaking, while 3.2% were Spanish-speaking. A key finding of this analysis was that
children from Spanish-speaking families were more likely to be subject to increased testing (i.e.,
chest x-rays, CBC, and blood cultures) compared to children from English-speaking families
(Adjusted OR = 1.29; 95% CI [1.05 -1.59]). Children from Spanish-speaking families were also
less likely to be admitted to inpatient units for continued management (OR = 0.80; 95% CI [0.65-
0.99]). In addition, higher odds of chest X-rays ordered (Adjusted OR = 1.5; 95% CI [1.2-1.9]),
complete blood count laboratory work (Adjusted OR = 1.7; 95% CI [1.2-2.5]), and blood cultures
(Adjusted OR = 1.7; 95% CI [1.2-2.4]) were found with Spanish-speaking families after adjusting
for age, triage, acuity, and prior visit. Additionally, these treatments led to increased care costs,
with no overall outcome improvement.
Pandey et al. (2021) used a grounded theory approach to interview patients and
practitioners regarding the impact of language barriers when accessing the healthcare system.
The authors utilized purposive sampling and collaborated with community partners to recruit
participants seeking English language services through an immigration settlement agency; 37
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individuals were interviewed. Likewise, the research group utilized purposive sampling to recruit
healthcare practitioners from a single community clinic primarily serving refugees, immigrants,
and other socially-disenfranchised groups. A total of 17 practitioners and administrative staff
consented to participate. The patient and practitioner groups were interviewed separately in
‘focus-group’ formats. The following themes were identified: (1) language barriers impeded
patient’s ability to access health information and services, (2) language barriers affected
partnerships with POC providers, (3) interpreter services were either unavailable or were sub-
par, and (4) language barriers led to poor health outcomes and a need for patients to ‘fill gaps’ in
their care. These themes highlight barriers to healthcare access and outcomes. Pandey et al.
discussed the impact on health care at all patient contact points and suggested that language
services at the point of delivery may not be adequate along the continuum of care. Authors
recommend that increased training and resources for interpreter services and policy change can
improve patient access and outcomes when language barriers interfere with healthcare services.
Lion et al. (2015) conducted a randomized control trial of the impacts of telephone versus
video interpretation services among Spanish-speaking patients in a 38-bed pediatric ED at Seattle
Children’s Hospital. A convenience sample of 290 Spanish-speaking families was established.
Life-threatening emergencies were excluded from the study, as were situations with concerns for
abuse, mental health threats, or if the patient was assigned a room before the interpreter modality
was announced. One week following their interaction, parents were surveyed via telephone
regarding personal demographic characteristics, quality of communication/interpretation in the
ED, how clinicians communicated in the ED, and their child’s discharge diagnosis. The
investigators reported that families who received video interpretation were more likely to
correctly name the child's diagnosis than those who received telephone interpretation (84 of 114
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[74.6%] vs. 52 of 87 [59.8%], respectively; p=0.03). Furthermore, patients in the telephone
group were more likely to report a lapse in professional interpreter services at 8% in the
telephone group and 2% in the video group (7 of 91 [7.7%] vs. 2 of 117 [1.7%], respectively; p =
0.04). Although there was no significant difference in overall quality between telephone and
video interpretation services, the authors posited that video interpretation allowed for more
engagement with non-verbal cues, enhancing communication.
Non-English-speaking patients may improve their chronic disease management outcomes
through language concordance with providers. Parker et al. (2017) used a pre-post, difference-in-
difference study to assess if language concordance between physicians and patients was
correlated with improved glycemic control (i.e., A1C < 8%) for Latinos with diabetes. The
investigators collected health data from over 1,600 patients who preferentially spoke Spanish and
the Spanish language proficiency of their providers. The research team compared A1C levels and
glycemic control between the language-concordant and language-discordant patient/provider
pairs. The investigators found a statistically significant 10% net increase in the prevalence of
recommended glycemic control in patients with Limited English Proficiency (LEP) who
switched from a language discordant to a concordant provider (p < 0.01; 95% CI [2% to 17%]).
Furthermore, the study showed a 9% increase in low-density lipoprotein control (p = 0.03; 95%
CI [1% to 17%]) in LEP individuals who switched to language-concordant providers.
Jaramillo et al. (2016) conducted a prospective study wherein families of children up to
the age of 18 were placed into three groups: concordant English-speaking (irrespective of ethnic
background), LEP concordant Spanish-speaking (Spanish-speaking patient and provider), and
LEP discordant Spanish-speaking using a trained interpreter (Spanish speaking patient and
English-speaking provider). A total of 156 participants were enrolled, with 47 families
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identifying as language discordant. The language-discordant participants asked significantly
fewer questions than the English-concordant group in a pairwise analysis with a difference of
3.21 in mean values (4.43 vs. 7.63 questions, respectively; p = 0.002), and the concordant
Spanish group with a mean difference of 2.56 (4.43 vs. 6.98 questions; p = 0.001). They also
reported that LEP discordant Spanish-speaking patients asked significantly fewer questions than
the English and Spanish concordant groups in an ordinary least square regression test (β = -2.48;
p = 0.02). Language-discordant parents expressed their desire to ask more questions but reported
that language barriers limited their ability to do so compared to language-concordant groups.
Wilson et al. (2005) conducted a telephone survey of 1,200 residents of California in 11
languages (Armenian, Cantonese, Mandarin, Spanish, Russian, etc.) to study the effects of
patient-provider language concordance on medical comprehension. The survey included four
categories of medical comprehension: problems understanding a medical situation, confusion
about medication use, trouble understanding medication labels, and bad reactions to medications
related to understanding instructions. LEP individuals comprised 49% of respondents, with the
remaining 51% identifying as English-proficient. The survey found that after adjusting for
confounders (language, ethnicity, age, sex, education, etc.), LEP patients were statistically
significantly more likely than English-proficient patients to report issues understanding a
medical situation (Adjusted OR 3.2, 95% CI [2.1 to 4.8]) and experienced adverse reactions to
medication (Adjusted OR 2.3, 95% CI [1.3 to 4.4]). LEP patients who had language-concordant
physicians were still significantly more likely not to understand medical situations (Adjusted OR
2.2, 95% CI [1.2 to 3.9]); however, they were not more likely to report issues with medication
use, understanding medication labels, or have bad reactions to medications when compared to
their English-proficient equivalents (Adjusted OR 0.98, 95% CI [0.5 to 1.9]; Adjusted OR 0.95,
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95% CI [0.5-1.8] respectively). The surveyors concluded that LEP patients, especially those with
discordant language providers, were at high-risk for adverse events. The researchers stated that
language concordance effectively reduces adverse reactions to medication use and stress, which
is crucial in improving patient outcomes.
After assessing 33 articles in a meta-analysis, Diamond et al. (2019) found that 76% of
the time, at least one patient outcome (blood glucose and blood pressure management for
diabetic patients, prognosis, and overall patient satisfaction) was better with language concordant
care compared to language discordant care. In addition, the researchers discovered that language
concordance was associated with lower colorectal cancer screenings and ED throughput times.
Conclusion
Language concordance fosters rapport and trust between the patient and healthcare
provider, leading to better patient engagement and patient outcomes. Research shows that
language concordance may not be equal or sufficient at all points of contact between provider
and patient, and these gaps could inhibit rapport, trust, and patient outcomes (Pandey et al.,
2021). We proposed that a simple language tool would facilitate language concordance and
improve outcomes between LEP patients and their English-speaking providers.
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Chapter 3
Methodology
This chapter details the design, tool development, setting, project population, protection
of human subjects, protocol, and data collection and analysis plan of our scholarship project. The
overarching aim of this project was to improve communication during the initial contact between
POC providers and language-discordant patients by designing, disseminating, and assessing
provider satisfaction with a multi-language communication tool. We first aimed to determine
POC provider satisfaction with their language-discordant communication processes. Next, the
project team developed a simple, phonetically spelled, multi-language communication tool for
POC providers to use at the initial contact points between Spanish, Armenian, Cantonese, and
Mandarin-speaking patients and English-speaking providers. The project team trained the POC
staff about the tool's purpose and use. The tool was then integrated into the POC workflow for
six weeks. Finally, the project team measured the POC staff’s satisfaction regarding the utility
and effectiveness of the multi-language communication tool.
Project Design
The project team measured POC provider satisfaction using a pre- and post-intervention
design. Preintervention surveys were disseminated in paper format to the project population of
interest. The preintervention survey was accompanied by a secondary survey that collected
nonidentifiable sociodemographic variables from the project participants. The postintervention
survey mirrored the preintervention survey and was collected at the end of the six-week
implementation period. Data from the pre- and post-surveys were analyzed.
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Communication Tool Development
The development of the multi-language communication tool addressed two points of
contact. A small, printed card was created with phrases: “Hello. My name is _____” and
“Mr./Ms. ____ for the preoperative clinic”. The first phrase was designed for the initial contact
point between patients and front office staff. The second phrase was used between patients and
back-office clinicians at the second contact point. The phrases were translated and spelled out
phonetically into Spanish, Armenian, Cantonese, and Mandarin. Cards were printed, laminated,
and added to patient charts for the administrative personnel. We contracted with California
Center for Translation and Interpretation to confirm that all translations were grammatically
correct. Appendix A details the simple phonetic communication tool used for this project.
After finalizing the language tool, we trained all POC staff on the tool. Specifically, the
project team hosted a live presentation at the POC, where the staff was presented with the
findings from the above literature review. The project team then provided staff with a visual
model regarding the use of the tool and its potential benefits. After the in-person education
session, the QI team performed a return demonstration with POC staff and made themselves
available to answer questions from the POC staff. The QI team then worked closely to integrate
the instrument into the provider’s workflow.
The chosen POC had an existing process for readily identifying non-English speaking
patients; specifically, the POC utilizes a color-coded chart system to identify non-English
speaking patients. The project team assessed the current workflow of the target POC and added
the appropriate language tool to the charts of patients previously designated as needing
translation services.
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Setting
The QI project was conducted in the POC of a major academic medical center in
Southern California. The POC evaluates and risk-stratifies patients scheduled for surgical
services at the associated medical center. In addition, the clinic optimizes patients ahead of their
planned surgery through care coordination, expert consultation, and prehabilitation when
appropriate. The POC has approximately 10,000 annually (J. Decker, personal communication,
November 7, 2022).
The patients who utilize this POC are linguistically diverse; data from the index POC was
collected between 2020 and 2021 regarding language services for patients 65 and older. That
data indicated that approximately 24% of visitors 65 and older speak a language other than
English. In descending order of prevalence, the top non-English languages patients report
speaking at the index POC include Spanish (11.2%), Armenian (3.8%), Mandarin (2.6%), and
Cantonese (2.6%). In order of decreasing frequency, other languages include Korean (2.5%),
Vietnamese (0.8%), Farsi (0.5%), Arabic (0.27%), Punjabi (0.13%), and Japanese (0.07%).
Given the size and scope of this scholarship project and the low patient volume of speakers of
the last six languages, these languages were not included in the final tool development.
When language discordance situations arise, the POC utilizes VRI services to connect
patients and providers with on-demand interpreters during the scheduled appointment. The VRI
platform at the index POC has two-way visual and auditory capabilities and is mounted on a
mobile station; however, these services are unavailable in the front office. Therefore, during
initial communication attempts, patients and providers must interact without interpretive
assistance and rely on rudimentary communication measures (e.g., gestures and hand signaling).
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Project Population
The project population consisted of the 22 staff members working in the index POC who
directly interact with non-English speaking patients. The staff included front office personnel,
medical assistants, registered nurses, nurse practitioners, and one physician. All front office staff
who initiate patient contact are fluent in English and Spanish.
Inclusion Criteria
We established the following inclusion criteria for project participation: all POC staff
who greet non-English speaking patients at the point of first contact (e.g., at the front desk) and
those clinicians who guide patients from the waiting room into the back examination room.
Exclusion Criteria
We excluded POC providers who self-reported proficiency in all four languages: Spanish,
Armenian, Cantonese, and Mandarin. These providers would not require VRI services to interact
with patients at the two contact points of interest. No participants met our exclusion criteria.
Project Surveys
We employed three separate paper surveys throughout this project. Although our initial
plan was to use a data collection platform, paper surveys were utilized for ease of dissemination
and to promote survey completion by the POC staff. The first survey collected participant
sociodemographic data. The remaining two surveys evaluated participant satisfaction before
using the novel communication tool and after the implementation period.
Provider Sociodemographic Data Survey
The sociodemographic survey accompanied the preintervention survey (Appendix B).
The survey collected the following data from POC providers: age, gender identity, practitioner
type, years of practice, education level, and self-reported non-English language proficiency. The
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survey did not gather identifiable participant information (e.g., names, home addresses, email
addresses).
Preintervention Survey
A POC provider preintervention survey addressed satisfaction across four communication
domains: satisfaction with the current process, perceived ability to establish trust at first contact,
perceived ability to build rapport with the patient during initial introduction, and satisfaction with
recent care facilitation (Appendix C). The survey included four questions: “I am overall satisfied
with current communication processes with non-English speaking patients,” “I feel that I am able
to establish patient trust at first contact,” “I feel that I am able to build rapport with the patient,”
and “I feel that I am able to adequately facilitate patient care regardless of language barrier.”
Questions were worded so that the score would progress positively. Responses were scored using
a five-point Likert scale; one indicated ‘strongly disagree,’ three designated neutrality, and five
corresponded to ‘strongly agree.’ Four was the minimum possible score, and 20 was the
maximum score.
The preintervention survey also included the following two additional open-ended
questions to assess communication barriers at initial patient contact: “Please list all the barriers
you face when interacting with non-English speaking patients,” and “Please provide any other
feedback about how best to establish trust, increasing rapport, and improving outcomes with
non-English speaking patients.” These open-ended questions enabled the POC providers to
express their individual concerns with established communication processes and allowed the
project team to uncover common themes that could be explored in this and future projects.
Questions were developed with our specific aims in mind and careful consideration for clarity,
bias, and wording sensitivity was used when developing the survey.
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Postintervention Survey
The postintervention survey mirrored the preintervention survey and asked the providers
about their satisfaction with communication attempts after implementing the communication tool
(Appendix D). The same four questions posed in the preintervention survey and the two open-
ended questions regarding barriers to bridging the communication gap were repeated. Questions
were scored using the same Likert scale and answer progression.
Protection of Human Subjects
The university and medical center director classified the scholarship project as a quality
improvement initiative. Therefore, IRB review and approval were not required or sought. Staff
participation in the quality improvement project was entirely voluntary, and participants could
withdraw from the project without penalty or prejudice.
Project Protocol
We instructed the POC to utilize the following project protocol to ensure consistency and
smooth progression.
1. Participants were educated regarding the purpose of the projects and were invited
to complete preintervention and baseline sociodemographic surveys. Surveys
were distributed in paper format as described above.
2. Throughout the six-week implementation period, providers were instructed to
identify Spanish, Armenian, Cantonese, or Mandarin speakers using their current
identification processes.
3. The office staff would then add the corresponding laminated and color-coded
language tool to the patient’s chart.
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4. After the patient arrives at the POC, front office staff should use the tool’s first
phrase, “Hello, my name is ______,” in the patient’s preferred language
(Appendix A) to greet the patient during initial contact at the registration desk.
5. Clinicians inviting patients from the waiting room to the examination room
should utilize the tool’s second phrase, “Mr./ Mrs. ______ for the preoperative
clinic,” in the patient’s native language (Appendix A).
6. After the implementation period, participants were requested to complete the
post-intervention survey.
Data Analysis
Execution of this QI project favored a descriptive, rather than inferential, analytical
approach. The collected data were non-parametric, so the QI team evaluated the pre- and post-
intervention score changes using medians and interquartile ranges. All survey items were
positively worded; therefore, agreement with the item scored higher for the data analysis.
Finally, we analyzed all open-ended responses for common themes.
Conclusion
This QI project aimed to bridge the communication gap between language-discordant
patients and providers. Encouraging and facilitating concordant language efforts has improved
patient trust, rapport, and outcomes. As such, after assessing provider satisfaction with current
processes, a simple, phonetically spelled, multi-language tool was developed and integrated into
the POC workflow. The QI team then measured the POC staff’s satisfaction regarding the utility
and effectiveness of the multi-language communication tool.
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Chapter 4
Results
This QI project aimed to improve communication during the first contact between POC
providers and patients who primarily spoke Spanish, Armenian, Cantonese, and Mandarin using
a simple, phonetically spelled, multi-language tool. To achieve the project aims, we developed a
language tool for POC staff to use during initial patient interactions. The tool’s specific phrases
were developed with input from the POC director and designed to address the needs of the
project location and population. Following this, official, certified translations and phonetics were
obtained. The tool was then printed and laminated to easily incorporate into the current POC
workflow. Finally, the tool and education regarding its use and importance were shared with
POC staff during a single, in-person education session. Preintervention and demographic data
were collected at the initiation of the project before the education session. Postintervention data
were collected after the six-week intervention period. Results, as well as their correlation to this
project’s specific aims, are presented below.
Baseline and Preintervention Survey Data
POC provider satisfaction with initial communication attempts with Spanish, Armenian,
Cantonese, and Mandarin-speaking patients was collected via paper surveys before
implementing the communication tool. A separate sociodemographic survey was administered in
tandem with the preintervention survey. The survey response was 14 out of 22 POC participants
(63.6%) for the demographic and preintervention surveys.
POC Participant Sociodemographic Data

Table 1 displays the sociodemographic information of the 14 participants. We collected
the following sociodemographic information: participant age, gender identification, professional
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role and, if applicable, non-English language proficiency, healthcare licensure classification,
years of experience in their current position, and highest educational level achieved. Most
participants identified as female (92.8%) and between the ages of 30-50 (92.8%). In addition,
most participants had more than six years of experience in their current role (71.4%).
Participants' educational experiences were broad, with seven participants' highest
academic level being an associate's degree or high school diploma and the remaining seven
having a bachelor's degree or higher. In initial conversations, the director of the POC indicated
that all front office staff are fluent in Spanish (J. Decker, personal communication, November 7,
2022).
POC Provider Satisfaction with the Existing Communication Model

Preintervention satisfaction data was compiled and presented in Table 2. The survey
response was 14 out of 22 POC participants (63.6%) for the preintervention survey.
Preintervention median (IQR) scores for questions 1-4 were 3(2-4), 3 (3-4.75), 3(3-4.75), and
3.5(2-4), respectively. Such scores imply that participants held neutral feelings about their
preintervention communication methods and their ability to establish trust, rapport and facilitate
patient care despite communications barriers.
Simple Novel Communication Tool
We developed a simple, phonetically spelled, multi-language communication tool for
POC providers to greet Spanish, Armenian, Cantonese, and Mandarin-speaking patients and
guide them to the appointment/examination area. The tool was developed with input from the
director of the POC medical director and translated using professional translation services. The
tool underwent several iterations to improve clarity and ease of use. Initially, the tool had each
phrase written in English with a direct translation underneath it. However, the Armenian,
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Mandarin, and Cantonese alphabets are not Latin based. Hence, a phonetic translation was added
to the tool. This was thought to increase readability and utility. A visual representation of the
multi-language tool can be seen in Appendix A.
Multi-language Tool Implementation
We implemented the multi-language tool in the POC of a major academic healthcare
system in Southern California. The implementation period began after a comprehensive training
session. It lasted six weeks, spanning from December 2022 to January 2023. The QI team had
initially planned on a four-week intervention period. However, secondary to a surge in winter
respiratory illnesses, there was a high staff absentee rate in the POC, and post-intervention
survey completion was lower than anticipated. As such, the QI team expanded the
implementation period to six weeks to capture a more robust post-intervention sample.
Communication Tool Utility and Effectiveness
We evaluated the instrument’s utility and effectiveness by measuring postintervention
POC provider satisfaction. This information was collected via paper survey after the six-week
integration period.
The post-intervention survey had a response rate of 12 out of 22 (54.5%) participants.
Postintervention survey data were presented with baseline data and are displayed in Table 2.
Questions 1 through 4 used a five-point Likert scale. The scale ranged from 1 (strongly disagree)
to 5 (strongly agree). Provider satisfaction with processes for communicating with non-English
speaking patients, establishing trust with patients at first contact, building rapport with patients,
and facilitating care with patients regardless of language barriers was slightly higher in the
postintervention group, with median scores of 4(3-4), 4(4-4), 4(3.75-4.25), and 4(4-4),
respectively.
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LANGUAGE TOOL RAPPORT AND TRUST
The survey posed two open-ended questions to the pre- and post-intervention survey
participants. The first question inquired about provider barriers during interactions with non-
English speaking patients. The second question invited participants to share feedback on how
POC providers might best improve trust, rapport, and outcomes in the clinical setting. We
obtained only a few responses, with one participant sharing information with the QI team per
question.
Descriptive data showed a slight change in the median aggregate satisfaction scores
between the pre- and post-intervention. However, we could not perform inferential analyses
because of an error in our data collection process. Due to a lack of matched pre- and post-
intervention survey results, this QI project could not use statistical analysis for nonparametric
comparisons. Although sparse, valuable subjective information regarding barriers to establishing
trust, rapport, and outcomes and strategies for improvement was also shared with the QI team.
Conclusion
In accordance with our project’s aims, we evaluated POC provider satisfaction with
established communication methods, developed and created a multi-language communication
tool, incorporated it into the POC workflow, and assessed provider satisfaction scores post-
integration. We estimated that the tool could bridge the gap between language-discordant
patients and providers at initial contact and increase provider satisfaction with their ability to
establish trust, rapport, and improve encounter outcomes. Although statistical significance was
neither sought nor obtained, provider satisfaction scores increased after the tool implementation
period.
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Chapter 5
Discussion
This QI project proposed that a multi-language communication tool could improve
provider satisfaction with initial communication attempts between themselves and non-English
speaking patients. We created a simple communication tool in the four most prevalent languages
experienced in our POC setting (Spanish, Armenian, Cantonese, and Mandarin). The project
location occurred at a major academic healthcare system in Southern California with an
integration period that spanned six weeks. We measured provider satisfaction with
communication with non-English speaking patients through pre- and post-intervention, short,
Likert-style surveys.
Specific Aims
This quality improvement project had four interrelated aims. We constructed each aim to
improve communication between providers and non-English speaking patients presenting for
preoperative evaluation and management. We proposed that enhanced communication between
POC providers and non-English speaking groups of interest would help improve trust, rapport,
and visit outcomes.
Specific Aim One
Our first specific aim determined baseline provider satisfaction with initial
communication attempts with Spanish, Armenian, Cantonese, and Mandarin-speaking patients.
We anticipated POC providers would be either strongly or somewhat dissatisfied with their
communication attempts with the populations of interest. We expected the result would be
consistent with Fields et al. (2016) and Steinberg et al. (2016), who found that language-
discordant patients and providers face increased challenges in establishing trust and rapport.
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However, POC staff were neither satisfied nor dissatisfied with their preintervention
communication processes with non-English speaking patients. When considering the staff’s
overall neutrality to this question, it is essential to reiterate that all POC front-office staff were
Spanish speaking; as the survey question aggregated all of the above groups within the
question’s stem, yet sought a singular response, it is possible that Spanish speaking providers
were more satisfied with their attempts at conversing with Spanish speaking patients and less
satisfied with their attempts at conversing with patients who spoke one of the remaining three
listed languages. In other words, their comfort with communicating with Spanish-speaking
patients may have influenced their response. Researchers might want to disaggregate this
question to better assess provider confidence with each language in the future. Comfort in
language concordance was an important finding by Andreae et al. (2017) and Aviera (1996), who
found greater ease in building trust and rapport between language-concordant patients and
providers.
Specific Aim Two
For specific aim two, we developed a simple, phonetically spelled, multi-language
communication tool for POC providers to greet Spanish, Armenian, Cantonese, and Mandarin-
speaking patients and call them to the back medical office. The project team designed the
language tool and tailored specific phrases according to the POC director's recommendations.
For example, our phraseology was crafted to summon patients for the preoperative clinic. The
waiting room for the POC is a shared space with different medical specialties utilizing it.
According to the POC medical director, when staff attempted to direct individuals to the POC,
non-English speaking patients often did not realize they were invited to the examination rooms
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or were confused about where to go. This resulted in patients sitting in the waiting room for
hours unnecessarily, leading to high frustration for patients and clinicians.
To rectify this issue, we discussed specific phrases and points of contact that would
significantly improve the POC workflow while also helping to establish trust, rapport, and visit
outcomes for LEP patients. We designed a two-phrase language tool and used a professional
language service to bridge the cross-cultural language gap. To ensure a correct translation for all
four index languages, we contracted with a commercial entity that specializes in certified
translations. Acquiring the translation service was simple. However, although the translations
were technically correct, the direct feedback from POC providers indicated that some of our
translations were imperfect for the context. For example, the word “for” in Spanish can have two
different translations depending on the context of the sentence. We suggest working with an
academic language department member during the tool development for future language
translation projects. Still, in working with an expert personally, future project teams would be
able to clearly explain the aims and design of the project and construct phrases that were both
technically correct and appropriate for the project aims.
Although our tool was specific to the POC setting, we relied on the national CLAS
standards (HHS, 2001), which mandate written and verbal tools for non-English speakers in a
healthcare setting to facilitate meaningful interaction between LEP patients and providers.
Additionally, the tool design was influenced by the findings of Diamond et al. (2019), Jaramillo
et al. (2016), and Wilson et al. (2005), who found that engaging with LEP patients in their
preferred language at first contact improved trust, rapport, and outcomes. Future translation
initiatives should consider specific language phrasing and customization for cultural sensitivity
and local community needs.
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Specific Aim Three
Specific aim three focused on implementing the multi-language tool at a POC embedded
within a major academic healthcare system in Southern California. Project rollout and
implementation were staged and complex but proceeded smoothly.
Staff education was straightforward regarding the project's purpose and design. We
developed a brief presentation, furnished exact copies of the language tool for review, and
provided staff with a ‘Frequently Asked Questions’ reference sheet. According to the staff, the
laminated tool was used multiple times and conveniently incorporated into the current workflow.
Intuitively, we knew that interventions were unlikely to be adopted if their implementation was
cumbersome or disruptive to staff, so we were encouraged by this feedback.
Although staff indicated initial excitement regarding our project, we discovered a
significant, unanticipated issue during implementation. The POC medical director stated that
some participants were “too shy” to use the language tool and communicate in other languages,
particularly Mandarin and Cantonese. This finding was consistent with other findings in the
literature. For example, Steinberg et al. (2016) and Zhao et al. (2021) reported that individuals
have difficulty or anxiety with speaking different, unfamiliar languages and expressed fear of
being misunderstood due to incorrect phraseology or a noticeable accent. It is possible that this
matter could have impacted data collection. While concerns about utilizing the Mandarin and
Cantonese translations were not shared directly with the QI team through survey data, we
acknowledge that the QI team did not directly ask if accent concerns might prevent the use of the
language tool. Furthermore, even if the QI team had posed this question, the same individuals
who were hesitant to speak another language might also have been reluctant to share that
information with the QI team directly. In reflection, posing these questions directly to
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participants might have provided additional information regarding the practical use of the
language tool.
For future groups interested in replicating this project, we recommend utilizing similar
education methods and tool formats. Additionally, we advise that interested project groups
emphasize how meaningful LEP patients find even cursory attempts at cross-cultural
communication. Hopefully, this would allay accent concerns and improve tool utilization.
Specific Aim Four
Specific aim four measured POC provider satisfaction regarding the utility and
effectiveness of the multi-language communication tool. The data from the post-intervention
closed-ended questions indicated increased provider satisfaction with communication with non-
English speaking patients, establishing trust at first contact with non-English speaking patients,
ability to develop rapport with non-English speaking patients, and ability to facilitate care
regardless of a language barrier. These findings were consistent with other communication
initiatives. Mayo et al. (2016) and Johnston et al. (2021) found that providers can communicate
better with LEP patients, increasing their satisfaction with the interaction. Although gains in
satisfaction scores were modest, the shift from neutrality to positive satisfaction in the post-
intervention period suggested that the language tool was valuable and beneficial.
We obtained two responses to our open-ended questions. One participant shared their
views about perceived barriers, while another discussed project improvement. Thematic analysis
was not possible, given the paucity of responses. The participant who reported on barriers made
two relevant comments. First, health information misunderstanding with non-English speaking
patients can arise when family members are translators. Lack of understanding of medical terms
and the inability to directly translate vocabulary from English to non-English and vice versa by
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an untrained individual can lead to misunderstanding and miscommunication with the patient.
Second, misunderstandings can occur when family members are utilized as translators in the
initial phases of an appointment, and certified medical translators are used later. The
participant’s concerns were echoed in an investigation by Wilson et al. (2005), who noted that
using family members instead of certified medical translators increased patient dissatisfaction
during the patient-provider encounter. We did not address changing translators during a patient
appointment, i.e., changing from family members to medically certified professionals. Our
project assumed that LEP patients would (and should) be initially engaged by staff directly; as
such, issues with pivoting from a proxy interpreter (e.g., a family member) to a medical
translator were not a pressing concern. However, this feedback was still valuable and a keen
remark for consideration. The concerns reported by our participants reflect legitimate interests
that have been addressed in the literature. Steinberg et al. (2016) noted that LEP patients would
often “get by” with a family member as an interpreter not to be a burden to healthcare providers
or because of a poor experience with translator services. Future projects should explore this issue
ahead of implementation.
Project Strengths
During the project’s educational roll-out, the QI team was encouraged by this project’s
perceived strengths. This project was the first initiative to bridge a language divide in a busy
POC within a large medical center. Informal staff feedback immediately following the education
sessions indicated staff excitement and buy-in; as language barriers were a well-known issue
amongst staff, there was a consensus that measures had to be taken to help improve meaningful,
initial engagement with non-English speakers.
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Despite some concerns or tool limitations, the project demonstrated the ease of use and
feasibility of implementing a multi-language communication tool to facilitate rapport, trust, and
patient outcomes. Other institutions can replicate and implement the project within their
healthcare systems. Expansion of the project should include other languages according to the
patient population of the individual healthcare system. This would further decrease the
disparities of language-discordant patients and improve rapport, trust, and patient outcomes. Care
should be taken to maintain project context that may need to be recovered in translation.
The multi-language tool was designed to be integrated easily into the current workflow of
the POC. The tool was laminated and color coordinated according to the already established non-
English speaking designation previously developed by the POC. Because of this, the tool could
be cleaned according to the facility’s sanitation guidelines and reused, limiting waste and
unnecessary expenditures.
Project Limitations
While we were encouraged by positive responses to our project, we noted several
limitations that hindered our data collection and statistical capabilities. For example, the data
collection period coincided with a surge in winter respiratory illnesses (specifically RSV [CDC,
2023a], SARS-CoV-2 [CDC, 2023B], and the flu [California Department of Public Health,
2023]). As such, the sample size was smaller than anticipated secondary to numerous sick calls
and employee absences at the POC. Furthermore, given the emphasis on QI, the project team did
not code participant responses to assess individual changes in pre- and post-test data. This
intentionally precluded the performance of inferential data analyses. For example, had the QI
team coded responses individually, we could have performed a Wilcoxon Signed Rank test test
which would have provided a clearer picture of changes specific to individual participants and
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LANGUAGE TOOL RAPPORT AND TRUST
allowed us to make more substantive statistical claims about satisfaction scores among sub-
populations of interest. Should subsequent researchers be interested in making higher-level
statistical claims, this project could be replicated to include inferential data analytics.
Additionally, and as noted previously, while the translations provided within the
language tool were technically correct, according to native Spanish speakers who engaged with
the tool, some felt they were inappropriate for our aims. For example, Spanish-speaking POC
members shared that there is a cultural difference between greeting someone formally for a
salutation instead of greeting someone to call them forth, and this difference was not adequately
captured with the language tool. So again, while professional and certifiable services were
employed to provide translation services, a lack of context may have affected the translations.
Looking forward, the QI team might revise the translations to be more appropriate to the context
rather than simply relying on a formal, word-for-word translation.
Recommendations and Future Research
After consideration of the current literature and analysis data, we propose the following
recommendations:
1. Incorporate a language tool or similar mechanism into a POC to facilitate
communication with non-English-speaking patients. When feasible, a language tool or
other similar means to enable communication between English-speaking POC providers
and non-English-speaking patients should be incorporated into the POC workflow.
2. Educate POC providers about cross-cultural communication. Engaging staff
frequently regarding cross-cultural communication can be achieved with current,
ongoing, diversity, equity, and inclusion efforts. In addition, emphasizing the importance
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of cross-cultural communication might allay POC provider fears about ‘not speaking
properly’ or having a beginner's accent.
3. Evaluate patient satisfaction with the communication tool and efforts. Based on the
literature review, it is clear that cross-cultural communication is essential to patient care.
However, understanding the patient’s response and perspective would be valuable to craft
a more personalized tool or communication framework. Additionally, knowing how
individual participants/groups respond to the language tool might improve efforts to tailor
educational resources for different languages and populations.
4. Expand the project's scope to include a welcome letter and an extended version of
the language tool. Engaging in multiple levels of cross-cultural communication
encourages trust and rapport building at initial contact, and providing non-English
speaking patients with a document explaining POC processes might help reduce anxiety
for POC staff. Additionally, providers frequently need to make or receive phone calls
to/from non-English speaking patients. As such, there is value in expanding the language
tool to include phrases like “Please hold for the translator.” These cumulative measures
facilitate timely and culturally competent care at numerous contact points.
Conclusion
Language is a critically important component of culture. Cross-cultural communication is
vital in establishing trust and rapport with their patients and improving outcomes. We
hypothesized that POC providers would be satisfied with a simple, phonetic multi-language tool
during initial contact with patients who primarily speak Spanish, Armenian, Cantonese, and
Mandarin in facilitating patient rapport, trust, and visit outcomes. The language tool improved
satisfaction in these areas. Given the positive staff response, future projects should include the
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patient perspective, a written welcome letter, and cross-cultural communication education for
healthcare providers. In addition, future research should consider inferential statistical analysis
for project generalizability. As a mechanism to facilitate cross-cultural communication, this
simple communication tool can increase provider satisfaction and improve patient trust, rapport,
and visit outcomes.

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LANGUAGE TOOL RAPPORT AND TRUST
Tables
Table 1
Participant Demographics
Baseline Characteristics n %
Age
18-25 0 0
26-30 1 0.7
31-40 5 35.7
41-50 8 57.1
Gender
Male 1 0.7
Female 13 92.9
Prefer not to answer 0 0
Role or Licensure Type
Administrative Staff 2 14.3
MA 5 35.7
LVN 0 0
RN 3 21.4
NP 3 21.4
MD 1 0.7
Years of Experience
<1 0 0
1-3 0 0
3-6 4 28.6
>6 10 71.4
Highest Level of Education
Highschool Diploma 6 42.9
Associate’s Degree 1 0.7
Bachelor’s Degree 3 21.4
Master’s Degree 3 21.4
Doctoral Degree 1 0.7
Note. N = 14.

46
LANGUAGE TOOL RAPPORT AND TRUST
Table 2
Pre- and Post-test Median Comparison
Question

Pre
(n=14)
Post
(n=12)
Median IQR Median IQR
1 3 (2-4) 4 (3-4)
2 3 (3-4.75) 4 (4-4)
3 3 (3-4.75) 4 (3.75-4.25)
4 3.5 (2-4) 4 (4-4)

47
LANGUAGE TOOL RAPPORT AND TRUST
Figures
Figure 1
PRISMA Flow Diagram

48
LANGUAGE TOOL RAPPORT AND TRUST
Appendix A
Language Tools

SPANISH
Phrase 1
English: “Hello, my name is (state your name)“
Spanish: “Hola, mi nombre es (state your name)”
“Oh-lah, mee NOHM-breh es (state your name)”

Phrase 2
English: “Mr. (state patient’s name) for the preoperative clinic”
Spanish: “Sr. (state patient’s name) por la clínica preoperatoria”
“Se-nyohr (state patient’s name) deh lah KLEE-nee-kah
preoh-pehr-ah-TOH-ree-ah”

English: “Mrs. (state patient’s name) for the preoperative clinic
Spanish: “Sra. (state patient’s name) por la clínica preoperatoria”
“Se-nyoh-rah (state patient’s name) deh lah KLEE-nee-kah
preoh-pehr-ah-TOH-ree-ah”

ARMENIAN
Phrase 1
English: “Hello, my name is (state your name)“
Armenian: “Ողջու՜յն, իմ անունն է”
“Bah-rev, eem ah-nu-nuh (state your name)”

Phrase 2
English: “Mr. (state patient’s name) for pre-surgical clinic”
Armenian: “Պարոն (state patent’s name) նախավիրահատական կլինիկայի
համար”
“Par-On (state patent’s name) na-kha-veera-ha-ta-kan klee-nee-kai ha-mar”
● P in ‘Paron’ is almost like a soft ‘B’
● The kh sound is very similar to the gh sound but much harsher

English: “Mrs. (state patient’s name) for pre-surgical clinic
Armenian: “Տիկին (state patent’s name) նախավիրահատական կլինիկայի
համար”
“Tee-keen (state patent’s name) na-kha-veera-ha-ta-kan klee-nee-kai ha-mar”

49
LANGUAGE TOOL RAPPORT AND TRUST

CANTONESE
Phrase 1
English: “Hello, my name is (state your name)“
Cantonese: 你好！我的名字是
“LAY-Ho. O-ko-meng-hai _______”

Phrase 2
English: “Mr. (state patient’s name) for the preoperative clinic”
Cantonese: ___先生（術前門診
“Seen-san. So-tzeen-moon-tzan”

English: “Mrs. (state patient’s name) for the preoperative clinic
Cantonese: ___夫人/ 女士術前門診
“Seu-u de. So-tzeen-moon-tzan”

MANDARIN
Phrase 1
English: “Hello, my name is (state your name)“
Mandarin: “您好，(state your name)”
“NEE hao wa de MING ju shu (state your name)”

Phrase 2
English: “Mr. (state patient’s name) to the preoperative clinic, please.”
Mandarin: “(state patient’s name) 先生，请到术前门诊部。”
“(state patient’s name) SHIN SUN , ching DAO SHU chien mee-ehn zehn BU”

English: “Mrs. (state patient’s name) to the preoperative clinic, please."
Mandarin: “(state patient’s name) 女士，请到术前门诊部”
“(state patient’s name) NU SHI, ching DAO SHU chien mee-ehn zehn BU”

50
LANGUAGE TOOL RAPPORT AND TRUST

Appendix B
Sociodemographic Survey

Directions:

Listed below are a number of statements about your sociodemographic information within your
current practice as a preoperative clinic provider. Read each item and circle which of the
following responses BEST describes your experience.

1. Age:
□ 18-25
□ 25-30
□ 30-40
□ 40-50

2. Gender identity:
□ Prefer not to answer
□ Man
□ Woman
□ Other

0. Role or licensure type:
□ Administrative Staff
□ MA
□ LVN
□ RN
□ NP
□ MD

0. Years of experience:
□ <1
□ 1-3
□ 3-6
□ >6

0. My highest level of education is:
□ High School Diploma
□ Associate’s Degree
□ Bachelor’s degree
□ Master's degree
□ Doctoral degree
0. I feel comfortable with my foreign language proficiency to accurately interpret and
understand my foreign language speaking patients in the following languages:
51
LANGUAGE TOOL RAPPORT AND TRUST
□ Spanish
□ Armenian
□ Mandarin
□ Cantonese

0. On a scale from 1-5 (1 being not at all proficient, 5 being the most proficient) how
proficient are you in the following languages.

Spanish ___ Armenian ___ Mandarin ___ Cantonese ___

0. If you speak any other languages (other than the ones listed above), list them below.

_____________________________________________________________________

0. I know how to say “Hello my name is_____” (or something very similar) in the following
languages:
□ Spanish
□ Armenian
□ Mandarin
□ Cantonese

0. I am able to call “Mr/Mrs X for the pre-op clinic” (or something very similar) in these
languages:
□ Spanish
□ Armenian
□ Mandarin
□ Cantonese

52
LANGUAGE TOOL RAPPORT AND TRUST
Appendix C
Preintervention Survey

Directions:

Listed below are a number of statements about your satisfaction with current practice at the
Preoperative Clinic at USC Keck Medical Center. Read each item and mark which of the
following responses BEST describes your experience.

I am overall satisfied with current communication processes with non-English speaking patients.

□ Strongly
Disagree
□ Disagree □ Neutral □ Agree □ Strongly
Agree

I feel I am able to establish patient trust at first contact.

□ Strongly
Disagree
□ Disagree □ Neutral □ Agree □ Strongly
Agree

I feel I am able to build rapport with the patient.

□ Strongly
Disagree
□ Disagree □ Neutral □ Agree □ Strongly
Agree

I feel that I am able to adequately facilitate patient care regardless of language barrier.

□ Strongly
Disagree
□ Disagree □ Neutral □ Agree □ Strongly
Agree

Please list all the barriers you face when interacting with non-English speaking patients:

Please provide any other feedback about how best to establish trust, increasing rapport, and
improving outcomes with non-English speaking patients.

53
LANGUAGE TOOL RAPPORT AND TRUST
Appendix D
Postintervention Survey

Directions:

Listed below are a number of statements about your satisfaction with current practice after the
introduction of the new language tool at the Preoperative Clinic at USC Keck Medical Center.
Read each item and mark which of the following responses BEST describes your experience.

I am overall satisfied with current communication processes with non-English speaking patients.

□ Strongly
Disagree
□ Disagree □ Neutral □ Agree □ Strongly
Agree

I feel I am able to establish patient trust at first contact.

□ Strongly
Disagree
□ Disagree □ Neutral □ Agree □ Strongly
Agree

I feel I am able to build rapport with the patient.

□ Strongly
Disagree
□ Disagree □ Neutral □ Agree □ Strongly
Agree

I feel that I am able to adequately facilitate patient care regardless of language barrier.

□ Strongly
Disagree
□ Disagree □ Neutral □ Agree □ Strongly
Agree

Please list all the barriers you face when interacting with non-English speaking patients:

Please provide any other feedback about how best to establish trust, increasing rapport, and
improving outcomes with non-English speaking patients.

Abstract (if available)

Abstract Cultural competence is a set of congruent behaviors, attitudes, and policies that enable systems, agencies, or professionals to work effectively in cross-cultural situations. In healthcare, cultural competence refers to the abilities of practitioners and systems to adequately integrate information about a patient’s unique values, beliefs, and behaviors and tailor their care delivery to meet specific social, cultural, and linguistic needs. The United States (US) Department of Health and Human Services (HHS) has acknowledged the importance of linguistically sensitive care and, in 2000, codified the national standards for Culturally and Linguistically Appropriate Services (CLAS). Following a comprehensive literature review and the generation of several best practice recommendations, the authors of this scholarship project created an educational model and written language tool. The educational tool was disseminated amongst preoperative clinic staff at a tertiary academic medical center in Southern California. Staff satisfaction surveys were issued pre- and post-intervention; staff satisfaction scores improved after introducing the communication tool. A simple communication tool can be quickly and effectively implemented to facilitate trust, rapport, and visit outcomes during an initial visit with non-English speaking patients in a preoperative clinic setting.

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Asset Metadata

Creator Bernas, Athena (author)

Core Title “First contact”: use of a language tool to increase rapport, trust and outcomes

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Degree Conferral Date 2024-05

Publication Date 09/12/2023

Defense Date 09/11/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag communication,language concordance,language discordance,OAI-PMH Harvest,preoperative clinic,rapport,trust

Format theses (aat)

Language English

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Advisor Bamgbose, Elizabeth (committee chair), Darna, Jeffrey (committee chair)

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