Winning Poster Project V.O.I.C.E - Valuing Opportunities for Inclusive Communication Excellence

Abstract

Background: Patients with limited English proficiency (LEP) often experience barriers to safe, high-quality care due to underutilization and inconsistent documentation of interpreter services. On the Inpatient Medical/Pediatric unit, HCAHPS scores for “Nurses explain things in a way I can understand” reflected this gap, with baseline performance at 50% at the end of FY24. Interpreter service use among pediatric patients was only 75% and documentation compliance was 83%. These findings highlighted a substantial need to strengthen equitable communication practices. Purpose: The purpose of this project was to improve interpreter service utilization and documentation accuracy while enhancing patient experience scores in communication-related HCAHPS domains. Methods: Using the DMAIC quality improvement framework, interprofessional team identified barriers including convenience, awareness, availability, knowledge gaps and documentation practices. Interventions included implementation of universal signage, creation of unit-based standard work and development of a structured staff education plan. Unit champions and clinical leadership supported adoption through real-time coaching, rounding and data feedback. Results: Post-intervention data demonstrated substantial improvement. Pediatric interpreter utilization increased from FY24 75% to FY25 91%, and documentation improved from FY24 83% to FY25 100%. Overall HCAHPs scores for the target domain rose from 50% at baseline (Aug 2024 end of FY24) to 77.8% (August 2025, FY25) by the end of the fiscal year. Additionally, language-related safety events (NETs) decreased from 11 to 1 over six months, underscoring the impact on patient safety and communication clarity. Implications for Practice: This project demonstrates that relatively simple interventions “standardize signage, clear documentation processes and focused education“ can yield measurable improvements in communication, equity and patient experience. Sustaining these results requires ongoing staff engagement and spread of interventions across additional units. Broader adoption of Project V.O.I.C.E can support system-wide goals of inclusive care and equitable communication for patients with LEP.