Don't overlook patients with low health literacy
Strategies to close communication gap
Patients are being put at risk because important health care information is communicated in medical jargon that exceeds their literary skills, according to a new white paper from The Joint Commission. (A copy of What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety is available at no charge on The Joint Commission web site, www.jointcommission.org, under "Public Policy Reports.")
"I think this is a huge blind spot, and we in health care are just now waking up to it," says Michael Leonard, MD, physician leader for patient safety at Kaiser Permanente in Evergreen, CO.
The paper says that the communication gap between patients and caregivers involves literacy, language, and culture, and gives 35 recommendations including education and training of leaders and staff on health literacy issues. The paper also recommends use of established patient communication methods such as "teach-back," and assessment of the literacy levels and language needs of the communities served.
Ninety million Americans "have difficulty understanding and acting upon health information," according to an Institute of Medicine (IOM) report on health literacy.1
Originally, health literacy was seen as an issue relevant only to certain patient population groups, says Rima E. Rudd, ScD, MSPH, a health literacy expert at the Harvard School of Public Health in Boston. "Only recently are institutions paying attention to the IOM claim that health literacy is an interaction between the skills of individuals and the demands of the health sector," she says.
Many health care professionals have recently started looking at their often faulty assumptions about what patients actually know and can do, and the nature of the demands they make, says Rudd.
Low health literacy is associated with several adverse health outcomes, including increased incidence of chronic illness and poorer intermediate disease markers, according to an Agency for Healthcare Research and Quality (AHRQ) report.2
In the near future, we may be seeing new requirements from The Joint Commission to address health literacy of patients. "I think over time, some consensus will be reached about possible solutions or fixes," says Rudd. "Once a consensus is reached, then I think we will see standards." To address health literacy at your organization, consider the following interventions:
• Assess commonly used forms, patient education print materials, signs and directions, informed consent documents, and discharge instructions. "Evaluate signage and patient education materials to be sure they are clear to people with low reading skills," says Patrice Spath, RHIT, a Forest Grove, OR-based consultant and author of the book Partnering with Patients to Reduce Medical Errors (published in 2004 by the American Hospital Association).
Many hospitals use printed material to encourage patients to speak up when they have a safety concern, but informational brochures used to communicate this are often written at a high grade level. People with low health literacy or non-English-speaking patients don't understand what is being stated in these brochures, says Spath. "Whenever possible, use pictures along with simple narratives to educate," she recommends.
• Provide a training and orientation program for all staff focused on health literacy awareness. "Develop a policy to address reading level of all in-house print materials for patients," says Rudd. "Train staff in use of plain language and how to avoid jargon."
• Ask about safety concerns verbally. Doctors, nurses, and patient advocates should be regularly asking the question, "Do you have any safety concerns?" says Rudd. "Avoid paper and pencil measures that only capture the opinion of those who read and write with ease," she says.
Consider the following "script" for a patient interview, says Rudd: "Many people point out that hospital staff often speak a 'foreign' language filled with medical and scientific words. We have been trying to use everyday words and clear explanations and directions as much as possible. We want to know what you think about our efforts."
- First, have you been here before?
- If yes: Have you noticed any change since you were here last?
- If no: Okay, now I will make some statements and want your response. Please use this scale to rate each of the following (1 means strongly disagree and 6 means strongly agree).
- Staff people are very clear when they give directions.
- When staff people use a medical or scientific word, they explain what it means.
- Doctors/nurses are very clear when they talk to me.
- When doctors/nurses use a medical or scientific word, they explain what it means.
- Doctors/nurses always ask me if they are clear or if they have left anything out.
- Doctors/nurses always ask me if I have questions.
- I know who to talk to if I have a safety concern or question.
- I know where to go if I cannot understand or use forms.
"We are continuously aware of the need to communicate to all our patients both in verbal and written messages that they can clearly comprehend and understand," says Thomas C. Royer, president and CEO of Christus Health, which has 40 acute care facilities, located primarily in Texas and Louisiana.
Administrators at Christus hospitals verbally ask these questions of patients and family members on their daily rounds: "Have the caregivers been identifying themselves to you? Is each person you encounter explaining what he or she is trying to do for you? Do you feel a trust or confidence in your caregivers?"
Similar questions are included in patient surveys conducted for inpatient and outpatient care, ambulatory surgery, and emergency departments, with written communications appropriately geared to the literacy level and language of the population each facility or program serves.
• Evaluate your progress.
To evaluate how well your hospital is doing at communicating with patients who have low health literacy, Royer suggests the following:
- Analyze the answers to the questions above and develop corrective action plans to address any deficiencies identified.
- Monitor re-admission rates to identify causes which might be related to the lack of understanding of discharge instructions.
- Have staff call ambulatory surgery patients or their designated contact to see how they are doing and to ensure they have full understanding of their post-operative instructions.
To identify patients with low health literacy, all patients at Christus are screened after triage for their financial insurance profile. The admissions clerks identify language barriers and obtain the necessary information with the assistance of an interpreter, and assess the patient and family's ability to comprehend and answer questions. "This information should be shared with the caregivers," says Royer. "It is important to note that the income level often parallels the health literacy level, making this process very useful."
References
- Institute of Medicine. Health Literacy: A Prescription to End Confusion 2004, Washington, D.C. National Academies Press.
- Agency for Healthcare Research and Quality. Literacy and Health Outcomes. Evidence Report/Technology Assessment Number 87. 2004. AHRQ Publication No. 04-E007.
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