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6
Reaction Panel 4
HEALTH LITERACY AND PATIENT-CENTERED CARE
Ana Pujols-McKee, M.D.
The Joint Commission
McKee began her presentation with an anecdote that illustrates how
health literacy challenges can be hidden. She was engaged in a telephone
conversation with a man who is in his nineties, and she happened to ask,
“What are you doing?” The man laughed and responded that he was
trying to file something but that he had forgotten the alphabet. Had she
not asked what the man was doing when she called, she would not have
realized that he was struggling.
The Joint Commission, McKee said, accredits and certifies 19,000
organizations and programs throughout the United States, including hos-
pitals, homecare, nursing homes, and ambulatory health care facilities.
The purpose of the accreditation process is to ensure safety and improve
outcomes within the organization. The Joint Commission has had expe -
rience with health literacy as far back as 2002 when it, in conjunction
with the Centers for Medicare and Medicaid Services (CMS), launched
the national Speak UpTM campaign.1 Other efforts have included the
following:
1 “In March 2002, The Joint Commission, together with the Centers for Medicare and
Medicaid Services, launched a national campaign to urge patients to take a role in prevent -
ing health care errors by becoming active, involved, and informed participants on the health
47
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48 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS
• Hospitals, Language, and Culture: A Snapshot of the Nation (2004)
• What Did the Doctor Say?: Improving Health Literacy to Protect Patient
Safety (2007)
• Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A
Report of Findings (2007)
• One Size Does Not Fit All: Meeting the Health Care Needs of Diverse
Populations (2008)
• Approval of new standards for patient-centered communication
(2009)
• Advancing Effective Communication, Cultural Competence, and Patient-
and Family-Centered Care: A Roadmap for Hospitals (2010)
• Health Equity Advisory Group—internal to the Joint Commission
and supported by a grant from the California Endowment
More recently, the Joint Commission has expanded its scope from
health literacy to include effective communication, cultural competencies,
and patient- and family-centered care. Effective communication is viewed
as a two-way process, where messages are negotiated until information is
fully understood by both parties. Cultural competency values diversity
and assessments, manages the dynamics of difference, and adapts to
diversity. Patient- and family-centered care is an innovative approach to
planning, delivering, and evaluating health care. In providing such care
organizations establish mutually beneficial partnerships with providers,
families, and patients, of all ages.
Joint Commission standards are principles that are based on con-
cepts which drive patient safety, process improvement, and protection
of patient rights. For every standard, there are elements of performance
that an organization must demonstrate. Four key areas of standards are
applicable to the attributes of a health literate organization described in
the paper, McKee said: leadership, human resources or workforce, provi-
sion of care, and the rights and responsibilities of individuals.
The standards related to leadership are focused on making sure that
the mission, vision, and goals of the hospital support the safety and qual-
ity of care, treatment, and services. The more one focuses on concerns of
patient safety, the more likely patient safety will capture the attention,
imagination, and innovation of the organization’s leadership. Another
element of leadership is ensuring that patients with comparable needs
receive the same standard of care, treatment, and services throughout the
organization.
care team. The program features brochures, posters, and buttons on a variety of patient
safety topics.” http://www.jointcommission.org/facts_about_speak_up_initiatives/ (ac-
cessed February 4, 2012).
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REACTION PANEL 4
A second area of standards relevant to attributes of health literacy
are the human resources standards. The Joint Commission allows the
organization to define the qualifications of its staff. That means there is
an opportunity, if the organization wishes, to include education in health
literacy as a qualification. Staff do participate in ongoing education and
training, some of which is required on an annual basis, and this is another
area where health literacy could be included. Finally, staff are evaluated
to ensure that they are competent to perform their responsibilities. Health
literacy could be included here as well.
The third area in which health literacy can be found in the Joint Com-
mission Standards is in the standards that define provision of care. The
hospital is expected to provide assessesments and reassessments of all
patients. Some of this may be especially pertinent to health literacy, for
example, if nurses are asked to assess a patient’s learning preferences.
There are many opportunities within this standard of assessment to iden-
tify issues of health literaacy. The hospital is also expected to provide
education and training, based on each patient’s needs and abilitities. One
of the elements of performance for this standard is that every patient
should identify his or her needs, which could potentially include issues
of health literacy.
The fourth area of standards concerns the rights and responsibilities
of individuals. A hospital must honor the patient’s right to give or withold
informed consent. However, if one were to closely examine the informed
consent process, one might find that many patients do not understand
what they are being told. Some of this is due to the way in which informa-
tion is presented, some is due to time constraints that foster quick interac-
tion, and some is due to the fact that the time at which the discussion is
taking place is a very emotional time for the patient.
A new Joint Commission requirement attempts to address some of
these issues by calling for patient-centered communication, bilateral com -
munication, or negotiating information until both parties understand
fully. The expanded standards now allow a family member, friend, or
other individual to be present with the patient for emotional support dur-
ing the course of the patient’s stay. There is also a requirement that the
hospital provide language interpretation and translation services.
The Joint Commission has published a document titled Advancing
Effective Communication, Cultural Competence, and Patient- and Family-
Centered Care: A Roadmap for Hospitals. One chapter provides a checklist
on how to assess an organization’s readiness to make the kinds of cultural
changes and competency changes that improve health literacy in the
organization, including the ability to use data in an effective way and the
readiness of the leadership and the workforce.
McKee said two attributes were most important. The first is “Promot-
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50 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS
ing health literacy as an organization’s responsibility.” When an organiza-
tion’s leadership is able to recognize a failure in communication with a
patient as a system failure, that is a very sophisticated organization. But
it probably also means that the organization has a culture of safety well
embedded throughout.
The second key attribute is the one that involves identifying high-risk
treatments and transitions. Relevant to this is the area of informed consent
discussed earlier. Improving health literacy capabilities in this area offers
a tremendous opportunity to improve safety.
All of the attributes should be integrated into the operational func-
tions of the organization—into patient safety initiatives, into patient expe-
rience initiatives, and into intiatives that involve community outreach or
employee engagement.
Those attributes that are potentially unfeasible are the ones that
require rich resources. Until there is information about the return on
investment for health literacy interventions, it will be difficult to convince
organizations, particularly those that are stuggling financially, that it is
valuable and important to move forward in those areas.
The Joint Commission is developing a method of evaluation called the
Tracer Method. Such a method will trace a patient’s journey throughout
the organization, from the point of admission or the emergency room to
the patient discharge. In this world of important transitions of care, it is
recognized that the tracer must also extend into the patient’s home, with
homecare, or into the long-term care facility. Evaluating an organization’s
ability to communicate confidently with the patients would be a compo -
nent in that tracer method.
It is the vision of the Joint Commission that all people, regardless of
their level of education, their ability to read, or their ability to understand
English should always experience the safest, highest-quality, best-value
health care across all settings. That statement is relevant to what makes
an organization health literate, McKee said.
AN EMPLOYER’S VIEW
John Neuberger
QuadGraphics
QuadGraphics was founded in 1971 and is the second largest printer
in the Western Hemisphere, Neuberger said. It has 28,000 employees in
80 facilities in North America, Latin America, and Europe. In the United
States the facilities are located in very different kinds of areas—some very
large and urban, others small and rural—and language issues arise in
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REACTION PANEL 4
many areas. About 20 years ago QuadGraphics started providing medical
care to its employees, including
• primary care clinics with selected subpecialties;
• wellness and preventive medicine programs;
• an occupational medicince program;
• onsite rehabilitation clinics;
• full-services laboratories, X-rays, pharmacies, and dental services;
• third-party benefit administration and utilitzation review;
• robust information systems; and
• telemedicine.
Health literacy is a cornerstone of a successful health care model,
Neuberger said. QuadGraphics, as is the case with any employer, needs a
healthy and productive workforce that works every day if the company
is to remain competitive in a very competitive market. The organization
is also concerned about population health for the 50,000 lives covered
under its health plan. If the consumers of care are not health literate, it
will cost both the company and the patient money. Health literacy is not
just an expense, it is an investment. The indirect costs of poor health lit -
eracy include low productivity, absenteeism, presenteeism,2 and increased
workers compensation claims. The company sees health literacy as one
of the cornerstones of managing costs, health, and wellness in consumer-
driven care.
Of the eighteen attributes discussed in the commissioned paper, sev -
eral are important to an employer such as QuadGraphics. One is “Provide
an infrastructure to avail frontline providers with educational supports
and resources.” It is important to have have reinforcements at the point
of service for what the provider (e.g., the physician, the dentist, the phar-
macist, or the physical therapist) has just told the patient. It is not enough
just to provide a brochure. It is important to work with the patient to be
sure that both patient and provider understand the issues involved in care
and agree on what needs to be done to take care of the condition. In the
company’s clinics 30 minutes per provider is allowed for each visit. The
company is willing to pay for this because it believes that allowing that
amount of time is effective in promoting health. It provides time for the
patient to focus not only on their ailment, but on prevention and wellness
issues, such as losing weight, stopping smoking, and family problems.
2 Presenteeism is “the measure of lost productivity cost due to employees actually show -
ing up for work, but not being fully engaged and productive mainly because of personal
health and life issue distractions.” http://ezinearticles.com/?Presenteeism:-The-Hidden-
Costs-of-Business&id=40408 (accessed February 5, 2012).
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52 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS
While interaction at the time of service is key, it is also important for
the patient to leave with appropriate written materials or a website ref-
erence that reinforces the information exchanged between provider and
patient. Even if the patient understands the information at the time of
the visit, it is likely that memory and understanding will fade with time.
Reinforcement of information is especially important for patients with
chronic conditions that need to continue to be managed.
Another important attribute is “Fosters an augmented and prepared
workforce to promote health literacy.” From the company’s perspective
this means the presence of integrated health teams to support the pro -
vider, including reception staff, the nurse, or others that work in the set-
ting. These staff need to be trained in health literacy and to be sensitive to
and understanding of the patient’s needs. With such a team the provider
can refer the patient to the appropriate staff for continued support—to
the dietician to talk about diet, the hygienist to discuss dental care, or the
receptionist to make the call to set up needed tests.
The team should reflect the socio-demographic profiles of the popula-
tion. Members should be prepared to translate the provider’s directions
into language that the patient understands, to check on understanding
and comprehension, to encourage questioning, and to focus on actionable
information.
Another important attribute is to “Make health plan and health insur-
ance products more transparent.” During open enrollment employees are
being asked to make tough choices. They need clear and plain communi -
cation. Before any vendor can send information to its employees, Quad -
Graphics must first review it to make sure it is understandable for the
population served. Plan descriptions need to be made more comprehen-
sible so that families choose the right plan for themselves. The company
counsels employees who are having difficulty understanding which plan
to choose. Employers have a major role to play in health literacy. They
need to engage the employee all year, not just at the time of enrollment,
and to encourage employees to take resonsibility for their personal health.
“Make systems more navigable for families working through the
health care system” is another important attribute for employers. There
are huge challenges in attemping to navigate the complicated and frag-
mented health care environment. Patients need to feel comfortable asking
for help.
There are major challenges to implementing policies and programs
aimed at becoming a more health literate organization, Neuberger said.
There are no immediate financial incentives for health care organiza-
tions. Are health care providers really interested in reducing utilization
of services under the current fee-for-service basis? Are they serious about
reducing emergency room visits, testing, and so on?
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REACTION PANEL 4
Information needs to be easily accessible to employees. QuadGraphics
is in the process of creating a webpage that will provide employees with a
variety of information related to their health benefits, including medical
and pharmacy benefits, flexible spending accounts, and claims informa-
tion. With such a page employees will no longer have to navigate mul-
tiple sites in order to obtain needed information. Employers also need to
develop an advocacy role so as to assist patients in choosing and navigat -
ing their health plans. Furthermore, employers can assure that all health
care materials are properly geared to various populations. That is what
QuadGraphics is doing—making sure that the information is relevant
to its different populations of employees. Employers have the financial
incentives to ensure that their populations are literate and can navigate
the health care system.
Employers are willing to work with providers in their communities
in order to create healthier populations. For example, there is one small
clinic in one of the QuadGraphic communities that wants to become a
medical home. To do so requires a nurse care manager to, among other
things, monitor patients. But the clinic cannot pay for a full-time care
manager. So the clinic approached QuadGrahics asking if the company
would be willing to pay half the salary, and it appears that the company
will do this because it is a good investment in employee health.
Neuberger concluded by saying that employers are incentivized and
can be partners in working with health care organizations to become
more health literate. Employers are willing to pay for better outcomes
and better care. However, it is important to have a system for document -
ing improvements—a system that can monitor patients’ understanding
of their medical conditions and provide information to develop better
practices in order to improve outcomes through improved health literacy.
THE CENTERS FOR MEDICARE AND MEDICAID
SERVICES (CMS) PERSPECTIVE
Shari Ling, M.D.
Office of Clinical Standards and Quality
Health literacy is an important topic at a critical time when the coun-
try is facing limited resources, Ling said. All of the attributes discussed in
the paper are important. They speak to different parts of the system and
different issues. Rather than discuss individual attributes separately, Ling
bundled them into a few categories and said she thought that it may be
worth considering the bundles in terms of what can be done immediately
using existing resources versus what requires more long-term solutions.
One could also think about them in terms of what is actionable rather
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54 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS
than what is ideal. Finally, perhaps those attributes that require health
system redesign could be reframed in terms of what can be accomplished
or achieved without a complete redesign—that is, what can be tackled
now.
The first of the attributes that is critically important—“Promoting
health literacy as an organizational responsibility”—falls into the bundle
of culture change and the acknowledgment that culture matters. Culture
matters for the patients and for the families; it is the filter through which
all information flows. This attribute is fundamental but is also the greatest
challenge. Other attributes in this bundle include the following:
• Encourage active inquiry, innovation, evaluation, and improvements.
• Encourage and expect question asking.
• Assess the communication climate.
• Recognize and overcome communication barriers.
• Target population health literacy advisory group.
Another important bundle of attributes relates to attention to content.
This is particularly crucial in the area of medication safety and communi -
cation about medication safety. Conversations around this issue must bal -
ance the risks versus the benefits of the recommended interventions. That
conversation is dependent upon the patient understanding and believing
what is being said, and understanding requires health literacy.
Infrastructure is another important bundle of attributes. There are
long-term and short-term infrastructure requirements. “Provider, patient,
and family technical assistance” could be provided immediately by offer-
ing educational materials that can actually be read and understood.
“Enhancing health care system navigability,” particularly across transi-
tions, could be addressed in the short term. Longer-term infrastructure
requirements include “Leveraging health information technology,” “Pro-
viding personal health records,” and, again, “Enhancing health care sys -
tem navigability.”
In an earlier presentation, Darren Townzen had offered a surprising
but informative piece of information when he said that even when per-
sonal health records are available, they are not necessarily used. What can
be done to make them usable? That is a longer term effort that needs to
be undertaken, Ling said.
The final bundle of attributes relates to developing needed skills and
tools for the workforce, the individual, and the community. There is an
opportunity for private and public partnerships to develop and apply
techniques that are never taught in medical school, for example, tech-
niques that are based on learning theories. What motivates an individual
to learn? How can understanding this motivation be applied in the medi -
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REACTION PANEL 4
cal setting? What lessons can be learned by both providers and patients?
The bundle includes the following attributes:
• Assess and track patient comprehension, skills, and problem
solving.
• Community resource awareness.
• Provider, patients, and family education resources.
• Promoting health plan and insurance transparency and compre-
hensibility—access and use.
• Curricula and threshold for health skills.
There are a number of implementation challenges. What will encour-
age corporations and the health care system to embrace the idea of
improving health literacy? From the perspective of the CMS, this requires
an evidence base. It also requies acknowledging that perception and
perspective matter: A message has to be perceived and understood in
order to be acted upon. At a system level it must be recognized that there
are burdens on the providers and the system. A provider has a specified
number of minutes to collect a patient history, conduct the examination,
and develop a plan with recommendations. And this is true even in a
system that has powerful electronic health records. Resources are a huge
challenge. How can these interventions be paid for? And finally, policy
change requires due process. Organizations are usually slow to change.
Stakeholder and public engagement and input are critical.
Encouraging the implementation of the attributes starts with a vision
and requires both strategy and resources. CMS is a major force and a trust-
worthy partner for the continued improvement of health and health care
for all Americans, Ling said. Figure 6-1 ilustrates the “three-part aim” of
CMS. At the center are the patient and the family, which means that the
challenge of achieving health literacy is itself at the center.
As for strategy, there is no “silver bullet,” Ling said. Many incen -
tives are needed to change behavior. Changing patient behavior relies
on literacy, on comprehension, and on understanding. Changing pro-
vider behavior has a different set of challenges, but theories of behavioral
intervention apply there, too. Intensive support must be offered for the
painstaking work needed to improve.
Figure 6-2 shows the various implementation levers for change. This
slide has been presented before with quality at the center, but the concepts
apply equally well with health literacy at the center. There are numerous
opportunities. The conditions of participation, or COP, can be seen at the
bottom of the diagram. CMS writes conditions of participation for all pro-
viders. If they want to participate, they must abide by the rules. Perhaps
the COP offers an opportunity for encouraging the attributes.
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56 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS
FIGURE 6-1 Three part aim.
SOURCE: Ling, 2011.
Figure 6-1
Bitmapped
Quality-improvement organizations are a potential lever for observ -
ing, studying, planning, and demonstrating improvement, and public
acknowlegment of a job well done can provide incentive. Existing quality-
improvement sites include Hospital Compare, Home Health Compare,
ESRD (End Stage Renal Disease) Compare, and Physician Compare. Per-
haps aspects of what matters in health literacy can be integrated into
the quality measurement and reporting schemes in these organizations.
Can some of the concepts embodied in these attributes, for example, be
extracted from the electronic health record in order to support a quality
measure construct? If so, that would support an operational and imple-
mentation strategy.
Patient safety is another avenue for incentives. Perhaps some of the
attributes could be integrated into the patient safety data formats offered
by the Agency for Healthcare Research and Quality. Other projects include
improving health literacy as a key component. Partnership for Patients,
which is focused on reducing hospital readmissions, is predicated on
the idea that such reductions can be achieved with increased patient
understanding and comprehension. The CMS diabetes disparities project
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REACTION PANEL 4
FIGURE 6–2 Implementation levers.
NOTE: Acronyms are as follows: ACOs are accountable care organizations; ARRA is the
American Recovery and Reinvestment Act; ASC VBP is ambulatory surgical center value-
based purchasing; CAH VBP is critical access hospital value-based purchasing; EQROs
are external quality review organizations; ESRD is End-stage Renal Disease; ESRD QIP is
Figure 6-2
End-stage Renal Disease quality incentive program; HH is home health; HITECH is the
Bitmapped
Health Information Technology for Economic and Clinical Health Act; IQR is inpatient
quality reporting; IRF is inpatient rehabilitation facility; LTCH is long term care hospital;
OQR is outpatient quality reporting; PRQS is physician quality reporting system; QIOs are
quality improvement organizations; SNF is skilled nursing facility; and VBP is value-based
purchasing.
SOURCE: Ling, 2011.
addresses cultural competency and improving health literacy through
better communication with Medicare beneficiaries in minority and under-
served populations.
Ling concluded her presentation by saying that the attributes dis -
cussed in the commissioned paper provide an opportunity for moving
the important health literacy agenda forward.
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DISCUSSION
Roundtable member Benard Dreyer said that his hospital was recently
surveyed by the Joint Commission. During the week that the surveyors
spent in the hopsital, not once did anyone ask about anything related to
health literacy or health communication, even though they asked about
many other specific things. Unless the importance of health literacy is
made explicit, he said, hospitals will not pursue it. Because hopsitals are
under a variety of pressures, they are only going to respond to those who
regulate or pay them. Those are the pressures that create change. How can
health literacy be made explicit in the ways that CMS regulates and that
the Joint Commission accredits health care organizations?
McKee said that the Joint Commission must achieve a balance
between being too prescriptive and too nondirectional. One opportunity
is provided by surveyor education and the need for a specific focus on
health literacy training. The training should address not only what to look
for and discuss with hospital staff, but also what to look for and discuss
with patients.
Ling said that health literacy must be spoken about, particularly
within the area of care transitions and patient safety. An actionable oppor-
tunity for CMS would be to examine its disparities data and to approach
health literacy through its quality-improvement efforts.
Roundtable member Will Ross said that the relationship of health
literacy to quality was not emphasized in the figure of implementation
levers (Figure 6-2). Yet that is what health literacy is about—improv-
ing quality. Perhaps the discussion should be reframed, he said. George
Isham, the roundtable chair, added that the figure is useful because it
provides a guide to potential points of action or influence. Another action
pathway to add to the figure would be access to health information tech -
nology and other resources for small private practices.
Ling said that the figure is meant to provide a framework of oppor-
tunities to think about. Reaching individual physicians and providers
is challenging. Avenues in the past have included educational sessions
in the context of the physician quality reporting program and electronic
health record incentives. Operational health literacy definitions and action
items would help tremendously.
Roundtable member Cindy Brach said that employers are important
players in encouraging health literate practices and that their purchasing
power offers them levels by which change can be encouraged. For exam -
ple, employers make decisions about which insurance plans to offer and
which providers to contract with. How would the attributes discussed in
the paper help an employer think about information provided by a health
plan and about its health literate practices? For CMS, will the information
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REACTION PANEL 4
in the commissioned paper help with developing surveyor training and
checklists they might use?
Neuberger agreed that employers do have a major role to play in
health literacy. Everyone has a stake in health literacy. Poor health literacy
contributes significantly to the cost of care because if patients do not com-
prehend what they are supposed to do, they don’t do it, which results in
poorer outcomes and greater costs. QuadGraphics has learned not to use
acronyms when explaining health plan options, Neuberger said. Provid-
ing incentives for preventive care and wellness programs is another way
to influence the options chosen.
Ling said that CMS values the concepts of health literacy. The dif-
ficulty comes at the operational level. How can the terms be defined in
ways that are measurable? What criteria should be used in determining
whether an organization is health literate? Is there a scale that could be
used and implemented within one of the quality reporting programs?
What are the sources of data? Having a data source would make it easier
for CMS to achieve health literacy objectives through the survey process
or the quality measurement, reporting, and improvement programs.
Brach said that the Agency for Healthcare Research and Quality has
developed a health literacy supplement to the Consumer Assessment of
Health Providers Survey.3 And the agency is about to finalize an HCAHPS
(Hospital Consumer Assessment of Healthcare Providers and Systems)
health literacy supplement and is currently working on one for health
plans as well. Ling replied that these would be wonderful tools to have.
Another thing that is needed, she said, is to demonstrate that health lit-
eracy interventions support affordability. Perhaps such efforts could be
included in the health care innovation challenge.4
McKee said that there is opportunity to provide education in health
literacy. The Joint Commission has sentinel event alerts that attract a great
deal of attention. Health literacy might be a topic for an alert. Further-
more, Joint Commission Resources5 might expand its scope of services to
include health literacy. Another opportunity is to assess health literacy as
a potential contributing factor when conducting a sentinel event review
3 The supplement “focuses on assessing providers’ activities to foster and improve the
health literacy of patients.” https://www.cahps.ahrq.gov/surveys-guidance/item-sets/
health literacy.aspx (accessed February 5, 2012).
4 A new CMS initiative that “will invest up to $1 billion in support of local innovation in
communities across the nation to achieve three-part aim outcomes: better care, better health
and lower costs through continuous improvement.” http://innovations.cms.gov/ (accessed
February 5, 2012).
5 Joint Commission Resources provides education, publications, consultation, and
evaluation regarding accreditation, standards development, good practices, and health care
quality improvement. http://www.jcrinc.com/About-JCR/ (accessed February 5, 2012).
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60 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS
or a review of any adverse event. One of the services that the Joint Com -
mission provides to its accredited organizations is being able to review
a sentinel event with the organization. There is a team of clinicians who
dedicate 100 percent of their time to reviewing these events. Commu-
nication is the theme that runs through most of the 900 sentinel events
reviewed each year. The traditional approach to a review does not get to
the granular detail of the communication defect, but rather it defines the
issue in general as a problem in communication. In general, the implica -
tions of health literacy may not be identified. If communication is the
theme, what often occurs is that the patient misunderstood instructions.
The defect is then assumed to be the responsibility of the patient, not the
organization or the process. McKee said she would examine how these
sentinel reviews could include a process that helps identify opportunities
with the organizations to address systemic literacy defects.
Roundtable member Yolanda Partida asked Ling whether she thought
there was an opportunity for CMS to create incentives for health promo -
tion and health preservation. Ling responded that CMS can implement
incentives within the limits of its authority. It can cover conditions and
can pay for medical services for Medicare beneficiaries that include an
annual wellness visit. Health risk assessment is still evolving. There is
an increasing acknowlegment that behavior matters, yet any new thing
proposed must go through rule making, which includes a requirement
that CMS consider and respond to every comment. That discussion is an
opportunity that plays out in a public forum during the course of rule
making.
Roundtable member Clarence Pearson asked Neuberger what argu-
ments could be advanced to employers to encourage them to support
health literacy in an environment where employees stay with the same
company for only 4 or 5 years on average. Neuberger responded that
where turnover is very high, it is more difficult to see a postive return
on investment (ROI). Yet for many employers wellness is a core strategy.
For employers paying the bills, wellness is a much better investment than
sickness.
Roundtable member Ruth Parker said that employers are key stake-
holders to engage and are incredibly powerful drivers. What about these
attributes is most useful in talking with employers? she asked Neuberger.
Neuberger responded that over the past few decades health plans have
mediated between the providers and the payers. As a result, employers
lost the opportunity to talk with each other on a regular basis. But health
care issues and costs are now so significant for employers that they are
hungry for discussion. They reach out to hospitals and health systems
around the country. Often the health care organizations think the entire
discussion is about price. And sometimes it is, but more importantly it
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is about outcomes, about creating and maintaining a healthy workforce.
Employers want to talk with those providing the care, to work together
to face key issues of improving care and outcomes.
Roundtable member Paul Schyve noted that the workshop discussion
on how organizations can become health literate involved three different
kinds of influences: the role of extrinsic requirements (such as those from
regulators or accreditors), the role of intrinsic motivation, and the role of
incentives. From the perspective of the Joint Commission, and probably
also of CMS, the preference would be to not hear that an organization
is doing something because it is required. These groups would rather
receive a thank-you for reminding the organization what needs to be
done, for evaluating how well it is doing, and for giving advice about
how to do it better because only if there is the intrinsic motivation does
one have a high level of success.
Either positive incentives (e.g., more pay) or negative incentives (e.g.,
less money) can be used to encourage the health literacy agenda. But there
are also perverse incentives, that is, putting in place an incentive system
that keeps an organization from doing what it intrinsically wishes to do.
And that, Schyve said, is a major problem in health care today.
The roundtable fosters discussions aimed at developing intrinsic
motivation. CMS and the accrediting bodies create extrinsic requirements.
And industry is trying to produce incentives as well, although it also has
extrinsic requirements in its contracting terms. But if these incentives
continue to operate in separate silos the result will be inefficieny and inef-
fectiveness. All three things are important—intrinsic motivation, extrinsic
requirements, and the incentives. At the same time, working collabora-
tively is needed in order to align these three influences.
Roundtable member Winston Wong agreed with the points that
Schyve made in the discussion about extrinsic and intrinsic incentives.
Benard Dreyer, while agreeing with the general discussion of intrinsic and
extrinsic incentives, said that there are many organizations that do view
health literacy as an intrinsic value, but they are under attack because of
limited resources.
REFERENCE
Ling, S. 2011. Centers for Medicare and Medicaid Services (CMS) Perspective. Presentation at
the Institute of Medicine Workshop on Attributes of a Health Literate Organization,
November 16. Washington, DC.
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