Patients with limited English proficiency (LEP) are prone to health disparities, including greater number of emergency room visits and lower satisfaction.^1-3 When patients receive care in their native language, perceived quality and satisfaction increases.^4-6

We noted a paucity of standardized non-English materials in our benign urology clinic. Accordingly, we designed a project to improve access to written discharge instructions for patients with LEP following clinic-based procedures.

What We Did

We aimed to increase the proportion of non–English-speaking patients who receive instructions in their native language after undergoing a procedure to at least 50% within the year-long pilot. Our implementation included 4 specific interventions (see Figure):

1. Curation of standardized discharge instructions in English for our most common procedures:
   • Cystoscopy
   • Ureteral stent removal
   • Voiding cystourethrography/retrograde urethrography
   • Urodynamics
   • Vasectomy
2. Translation into our most common languages:
   • Chinese
   • Spanish
   • Russian
   • Vietnamese

Note: To maintain reliability and integrity, only official translation services at our hospital were used.

3. Implementation of printed copies to be distributed with after-visit summary material.
4. Creation of an online repository and posting a QR code in patient-facing clinic spaces for electronic access.

Figure. Implementation process diagram for introducing non-English discharge instructions in the ambulatory urology clinic.

Before implementation, we met with the clinic staff to understand existing workflows and adapt our intervention to be best suited and least disruptive. Monthly check-ins were then held throughout the year to assess our progress and address barriers, during which targeted and open-ended feedback was sought from the staff to understand what was working and what was not.

No funding was required for this project, demonstrating the feasibility of such interventions even with limited financial support. Fortunately, our translation services waived the fees for translating the documents because of the patient-facing nature of the material. The main cost involved printing the documents, which was negligible. Online documents were maintained within REDCap hosted at our institution, and accessible through a QR code using the survey feature of this software.⁷ To measure our progress, the number of translated documents downloaded or given out was compared to the number of eligible appointments.

What We Found

We successfully increased the number of non–English-speaking patients who received language-concordant instructions to above 50%, reaching as high as 91%. Future measurements include assessing the impact on patient satisfaction and the change in after-hours or emergency service usage following the intervention. We will also expand the material to include pre- and postsurgical information and general educational documents.

Barriers centered mostly around changing behavior in the clinic. This was addressed during the monthly check-ins, in which we aimed to fit the new process into existing workflows. For instance, the written instructions were initially stored in procedure rooms; however the staff identified it would be easier to keep them at the front desk with the patients’ charts. This simple change increased adherence substantially. These check-ins generated great ideas and created a sense of pride and ownership in the clinic staff regarding the project.

What We Learned

Lesson 1: Meeting with stakeholders during the planning stage is key. Only those on the forefront of implementation truly know the barriers and strategies to overcome them. These meetings garner buy-in from those on the front lines, generate ideas from diverse and invested stakeholders, and help gain a true understanding of existing gaps.

Lesson 2: Ongoing check-ins and adaptability ensure success. No project is perfect from the beginning. We recommend periodic progress report meetings with stakeholders throughout the process. One should expect to change course and adapt creatively when unanticipated barriers inevitably arise, rather than falling into the trap of adhering rigidly to an initial protocol.

Lesson 3: Keep interventions simple and efficient. Our health care system is fraught with oversized problems that are difficult to address under a single effort. Looking for opportunities that maximize impact while minimizing interventions has the highest chance of success. Simple, “bite-sized” interventions can have a significant impact and are often easier to implement, especially when resources or manpower are limited. Moreover, the foundation laid during early initiatives can set the stage for more impactful projects later, leading to additive effects over time.

Lesson 4: Projects like this are important. Patients with LEP are a vulnerable population that experience worse care due to many factors. The appreciation and gratitude many patients expressed, simply from receiving care in their native language, was remarkable. Lowering barriers to care and doing so in an intelligible way is the right thing to do for these patients, regardless of its effect on measurable metrics.

Patients have the basic right to care that is understandable and appropriate. Through our simple intervention, we were able to increase the number of instructions provided to non–English-speaking patients who underwent a procedure in our benign urology clinic, and thus provide improved care to this at-risk population.