National Academies Press: OpenBook

Organizational Change to Improve Health Literacy: Workshop Summary (2013)

Chapter: 3 Panel 2: Implementing Attributes of a Health Literate Organization

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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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3

Panel 2: Implementing Attributes of a Health Literate Organization

THOMAS BAUER, M.B.A.

Director, Research Development and Implementation of Health Literacy, Patient Empowerment, and Cultural Competence Initiative Novant Health

The following is a summary of the presentation given by Thomas Bauer. It is not a transcript.

Novant Health is actively pursuing implementation of the 10 attributes of a health literate organization. The first attribute is that the organization has leadership that makes health literacy integral to its mission, structure, and operations (Brach et al., 2012). An indication that Novant Health has such leadership is that health literacy was included in the organization’s 5-year strategic plans for 2010 and 2015. That decision was the result of research and discussion with stakeholders, including patient partners, physicians, and providers, who indicated that health literacy was an issue.

Health literacy is also included in Novant Health’s corporate dashboard (which measures key corporate goals visually) through behavioral assessments and HCAHPS1 outcomes. One of the areas added to the

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1 HCAHPS stands for Hospital Consumer Assessment of Healthcare Providers and Systems. It is a national, standardized, publicly reported survey of patients’ hospital care experience. See http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet%20May%202012.pdf (accessed June 5, 2013).

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

dashboard in 2013 will be the results of patient surveys measuring health literacy. Patients will be asked randomly throughout the year if they can explain their main health problem, what they need to do, why it is important, and if someone has asked them to repeat back some of the instructions that they have been taught. The results will be reported at the corporate level and to the board of directors. In addition, health literacy is included in patient education, communications, patient experience, and safety policies and procedures and is built into the design of Novant’s electronic health records system, the Epic Health Information System (EPIC). In 2009, Novant Health hired Bauer as the corporate director of Voice and Choice to lead the health literacy effort.

To meet the second and third attributes—integrating health literacy into planning, evaluation measures, patient safety, and quality improvement and preparing the workforce to be health literate and monitor progress—Novant Health has trained 19,000 providers and clinical staff throughout the organization. Following the training, each staff member was required to take a test. The organization then conducted staff assessments on the ability to apply the training. The result was that 96 percent of staff were able to use the skills they had been taught. Novant Health’s patient education standards also require that all patient education materials be written at a fifth-grade level, and clear communication is an important part of Novant’s safety initiative. This concept is interwoven throughout all of the organization’s policies, procedures, and the mainframe of Novant Health.

The fifth attribute of a health literate organization is that it meets the needs of populations with a range of health literacy skills while avoiding stigmatization. To do this, Novant Health applies the universal precautions methodology2 to address health literacy issues. The staff have also been trained to use simplified language, a modified Ask Me 3, and teach-back. Bauer explained that the organization had modified the Ask Me 3 method in a manner that worked better in the organization’s clinical context. He stressed that the organization is working toward a goal of 100 percent staff use of these programs.

The use of the modified Ask Me 3 and teach-back has also been important in achieving the sixth attribute, using health literacy strategies in interpersonal communications and confirming understanding at all points of contact. Novant Health also uses a method called “chunking

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2 For information on the universal precautions methodology as it applies to health literacy, see Agency for Healthcare Research and Quality (AHRQ), Health Literacy Universal Precautions Toolkit, http://www.ahrq.gov/legacy/qual/literacy/healthliteracytoolkit.pdf (accessed September 7, 2013).

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

and checking,”3 which was a challenge to put in place but has proved successful.

Novant Health has also become more adept at using interpreters. The interpreter services area was moved to a corporate function, and the organization has conducted extensive training so that people understand when and how to access an interpreter. There has been a lot of progress in that area in the past year. Interpreters are trained to be advocates for the use of Ask Me 3 and teach-back. Not only are they interpreting, Bauer said, they are teaching the patients about Ask Me 3 and teach-back. Patient education materials are now available in up to 15 languages. In addition, the organization is now using the Ask Me 3 questions to format written patient education materials. Novant Health created patient education materials called focus sheets, which are one-page documents that answer the three questions of Ask Me 3 for the condition being presented: What is my main problem? What do I need to do? Why is it important for me to do this? This innovation has been very successful, said Bauer. He also noted that these activities are important to the eighth attribute— designing and distributing print, audiovisual, and social media content that is easy to understand and act on.

Novant Health is in the process of installing MyChart, a patient portal that provides controlled access to individual health information, as a part of EPIC. This tool will promote the seventh attribute—providing easy access to health information and sources of navigation. MyChart is a powerful tool for communication between patient and provider. Novant Health has also implemented electronic patient scheduling in some of its clinics and continues to expand this service.

Novant Health has also been working aggressively to achieve the tenth attribute, communicating clearly what health plans cover and what individuals will have to pay for services. As of April 17, 2013, all of the health system’s registration materials will be written at a fifth-grade level. Bauer said they converted a five-page document that included financial responsibilities in the informed consent material into a two-page document with a lot of white space. There will also be a tool to estimate out-of-pocket expenses. Easy 3, a modification of Ask Me 3, was developed by and has been implemented in the business office to explain benefits.

Novant Health’s transformation into a health literate organization began with research. The health system covers four states: Georgia, North Carolina, South Carolina, and Virginia. It was important for the organization to ask, “What did those communities need from Novant Health? What did the patients, insurers, providers, and clinicians want? What

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3 In this approach, information is broken down into small pieces, and once each piece is delivered, the recipient is asked to show that he or she understands the information.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

were the driving forces?” Figure 3-1 shows some of the research that was undertaken.

After Novant analyzed the research and information that had been gathered, Bauer said, four themes emerged:

  1. Making things easy. Easy For Me takes into account that health care is complex, difficult to navigate, and difficult to understand. People need easy access and easy understanding.
  2. Authentic personalized relationships. People are looking for authentic personal relationships with their health care providers.
  3. Safety. People are looking for quality and safety.
  4. Voice and choice. This theme includes health literacy, patient empowerment, and patient activation.

Novant Health hired coaches for each one of the four themes, including Bauer as the coach for voice and choice.

In 2009, Bauer began extensive research on health literacy and what the organization could do to improve health literacy among patients and providers and at the system level. Out of this research, Ask Me 3 and teach-back emerged as the possible methods to address low health literacy, so a pilot program using these methods was begun. The pilots were implemented in four hospital units and in four different physician

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FIGURE 3-1 The beginning of the journey: Extensive research.
SOURCE: Bauer, 2013.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

practices. They included different geographical areas, rural and urban, and different types of practices. The implementation and testing occurred over the course of a year. The pilot programs showed that Ask Me 3 and teach-back worked well when modified to better fit the context of the situation. In the office setting, when patients were prompted to ask questions, often they did not, and at times they became irritated. As a result, Bauer said, Novant Health has backed away from that strategy.

The elements of the modified Ask Me 3 program focused on framing the conversation using the three essential questions of Ask Me 3. In addition to focusing on defining the problem and a course of action, the provider also learned to communicate why it was important. Once a person understands this, he or she is much more likely to follow the plan of care, be more active in the conversation, and make a joint decision, Bauer said. In addition, teach-back was implemented along with using simplified language and asking providers to sit and make eye contact with patients in order to form a personal relationship.

At Novant Health, there is a program called the Senior Leadership Academy. In response to the results of the research, that academy began work on health literacy, which helped garner support for the effort as a whole. The organization engaged Darren DeWalt to help work on health literacy efforts in congestive heart failure at Presbyterian Hospital in Charlotte, North Carolina. Eventually, physician leaders emerged, and those physician champions began to excite the rest of the organization. As the work continued, it gathered more physician leaders and nursing leaders, and then, because of the results, a number of presidents of hospitals became very interested. This interest led to some healthy competition among parts of the organization that wanted to be the first to implement health literacy measures.

As the implementation spread systemwide, the success of the initiative led to a corporate mandate that Ask Me 3 and teach-back be used throughout the organization. The corporate mandate indicated a culture change, and health literate behaviors became an expectation. Bauer said that a key lesson from the experience was that when an action is expected it becomes more accepted at all levels.

The results of implementing Ask Me 3 and teach-back in the clinical realm were significant. To measure the impact of the programs, the organization asked patients in a stroke center who were not cognitively impaired and who had not been exposed to Ask Me 3 or teach-back to describe what had happened, what they needed to do, and why. Prior to implementing health literacy measures, the first two questions could be answered with heavy prompting and the third question hardly at all. After exposure to Ask Me 3 and teach-back, patients displayed full recollection of the information they had been given. Terminology also played

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

a role, according to Bauer, in that providers are not always consistent, sometimes referring to strokes as “small bleeds” or “aneurysms.”

In one of the original studies to determine the need for health literacy, patients with congestive heart failure were administered a test. If they could pass the test, then it was assumed that they could manage their disease. The average score on the test, when it was originally administered, was 38.5 percent. After the use of Ask Me 3 and teach-back, the score rose to 85 percent, where it has remained for more than 2 years. The result was a reduction in preventable readmissions of about 44 percent. There was also a significant increase in patient satisfaction. Everywhere that Ask Me 3 and teach-back were implemented, patient satisfaction levels rose, particularly in the area of explanation of treatment. There was also a rise in reported joint decision making at every site.

There were several barriers to implementation. First, system capacity for change was limited. Health care evolves quickly, and the ability to change is an issue for the entire field. Providing consistent training for almost 20,000 people is difficult, and sometimes people do not realize that they have not communicated effectively throughout their career.

Sustaining change is also a challenge. Bauer said that Novant Health is committed to health literacy and to remaining a health literate organization. The organization has dedicated points of contact in each of the facilities to help hardwire the change into the system. The organization is embedding health literacy in its best practices and in systems and processes. Health literacy is a part of the patient-centered medical home, and the patient education process is contained within those systems.

Bauer concluded his presentation by saying that the organization’s next steps are implementing the AHRQ Health Literacy Universal Precautions Toolkit and assessing and determining what tools are necessary for the practices. That process will begin as part of the patient-centered medical home. Novant Health expects that, in the coming months, 28 practices will have completed assessments, and implementation plans will be developed as a result of those assessments.

KAREN KOMONDOR, R.N.

Director of Education and Health Literacy Institute St. Vincent Charity Medical Center

The following is a summary of the presentation given by Karen Komondor. It is not a transcript.

St. Vincent Charity Medical Center is a 250-bed urban not-for-profit teaching hospital in the heart of downtown Cleveland, Ohio. It is one of

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

five hospitals in the Sisters of Charity Health System, which has three hospitals in the Cleveland and Akron areas and two in South Carolina. St. Vincent has been working in health literacy for 6 years. In 2007, the hospital was awarded a grant from the Sisters of Charity Foundation in collaboration with Project Learn, an adult learning center located in Cleveland. At that time, Komondor was director of education and was brought in to be a part of the project. The hospital held community discussions and met with other grantees from the foundation. Komondor said that she was not familiar with the term “health literacy” when the project began, but she saw that it gave a name to an issue that she had often thought about.

One of the hospital’s first initiatives was to form a health literacy team and combine it with the patient education committee. This team has been meeting monthly for 6 years, Komondor said. There are 12 members, with each member representing a different discipline in the hospital. The disciplines include pulmonary, radiology, diabetes education, mission and ministry, nursing, pharmacy, rehab services, quality, deaf access, information technology, community outreach, and marketing.

Initially, the hospital’s efforts focused on training, and over the years, the team has found that training needs to be ongoing, Komondor said. The first health literacy task was to increase awareness, because not many people realized that health literacy was an issue. Although a patient education team had been in place for many years, the team needed to be trained on health literacy principles. The health literacy team leadership was able to attend the American Medical Association’s Train the Trainer Program and returned to the hospital to spread lessons learned to other members of the team. Nurses and medical residents were two other important target groups identified for increased awareness. The initial focus was on raising awareness and sharing tools, such as plain language and teach-back. Training has evolved considerably since those initial efforts, Komondor said.

In 2007, the health literacy focus was on the low-literacy population, but as more tools (such as the Health Literacy Universal Precautions Toolkit) became available, the hospital incorporated many different techniques into its training. Every caregiver at the department level has been trained, and there is support from all of the department directors. Members of the health literacy team have been invited to different staff meetings in every hospital department to share health literacy principles. St. Vincent defines health literacy as not only the patient’s ability to understand and act on health information, but also the provider’s ability to share that information in a way the patient can act on.

The hospital has incorporated health literacy into new employee orientation, which takes place monthly, so every caregiver beginning work at St. Vincent receives about an hour of training in health literacy. The

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

training has been expanded to include annual health literacy competencies along with clinical competencies for every caregiver.

The hospital is also working toward achieving the eighth attribute of health literate organizations—designing and distributing print, audiovisual, and social media content that is easy to understand and act on. One of the first objectives was to assess current patient education materials. A random sampling of patient education materials used at the hospital showed that the average reading level was about twelfth grade. The hospital also did an assessment of patient education materials provided by a vendor and found that those materials were at an even higher level. Most of the materials were very lengthy; one set of discharge instructions was 17 pages long. As a result, Komondor said, the hospital stopped using that vendor’s materials.

Now all of the in-house patient education materials have been revised to a fifth- or sixth-grade reading level. The new vendor provides materials that are at the same level. All the materials are available in Spanish because Spanish speakers make up the largest percentage of the minority population that uses St. Vincent, and many of the sheets are also available in multiple other languages.

The hospital also wants to improve interpreter services and has decided to go with a vendor that uses a video system. Because the hospital serves a large deaf population, the ability to interpret for American Sign Language is necessary. The hospital has also purchased health education videos that are available in every inpatient room, along with a content guide. All of the nurses have been trained to encourage patients to look at the guide, Komondor said. For example, a patient admitted for a cardiac catheterization will receive information from the nurse and be encouraged to view the appropriate videos.

Another major effort has been to involve the adult learner students from Project Learn in different focus groups. The adult learners are brought in to assess the print materials developed in house, and the materials are revised until they make sense to them.

The hospital has also used the adult learners as navigation tracers. On three different occasions, the adult learners were brought to the lobby of the hospital and asked to find a particular location, such as CT (computed tomography) scan or radiology. They were asked about their experience in navigating the hospital. Findings were that although the caregivers were happy to help when asked for directions, the signage in the hospital was not clear. With the support of senior leadership, the health literacy team held further focus groups with these adult learners. The students were given a list of all the hospital departments and asked for input on terminology used. On the basis of what was learned, the hospital’s signs were changed. Instead of “Radiology,” for example,

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

the sign now reads “X-ray.” The new signage is also in Spanish as well as English.

Sometimes language can seem benign but still prove to be a barrier, Komondor said. For example, the department where patients check in for tests was called “Admitting,” but patients were not being admitted to the hospital in that area. The name has since been changed to “Patient Check-In.”

The hospital was also interested in addressing high-risk populations and high-risk procedures. One target area for improvement was the process for education about heart failure. The information booklet Caring for Your Heart: Living Well with Heart Failure from the North Carolina Program on Health Literacy is a great tool, and the response from patients is that it is working well, Komondor said. The hospital has revised the way questions are asked and incorporated changes into the computer documentation. Nurses now follow a guide to assessing knowledge, skills, and attitude. For example, on the first day, the nurses address teaching knowledge. On the second day, the questions are reformatted to cover the same information, but the focus is now on skills. Finally, on day three, the questions are reframed to emphasize attitude.

In another effort, clinical pharmacists are now involved in education about heart failure. The clinical pharmacists visit patients in their rooms and teach them about medication. They are also present at discharge to go over medication reconciliation with the patients, and they perform follow-up calls with the patients.

When patients were questioned about the barriers they face in following a treatment plan, many reported that they did not have scales at home. Now, the hospital provides a scale to patients who do not have one at home.

Another focus area for the hospital is informed consent. The health literacy team has developed an informed consent document that covers everything in plain language.

Leadership support for health literacy has been enormous at St. Vincent, said Komondor. There is a health literacy institute that sets its own team goals and has its own budget. Health literacy measures have been incorporated into hospital policies, including the use of plain language, universal precautions, and a teach-back technique.

Beginning in 2007, the primary goal of the organization was to develop a program model that would institutionalize health literacy at St. Vincent. Komondor said that she thinks they have made good progress. The administrative leadership at St. Vincent has changed several times since the program’s inception, but sharing the personal stories and results of the research has convinced senior leadership of the importance of health literacy and ensured continued support.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

One of the main barriers to health literacy is finding adequate staff time. The health literacy and patient education department is small and has a number of duties. Another barrier is a lack of buy-in from attending physicians. This will be the next target audience for building awareness and support.

To sustain the changes within the organization, the team has included them in new employee orientation and mandatory annual competencies. The health literacy team has also held conferences and workshops. In 2012, they hosted a conference series and four different short workshops on writing for easier reading. This effort culminated in the October Health Literacy Month Inaugural Ohio Health Literacy Conference, which had about 200 attendees, including physicians, nurses, and others from a wide array of disciplines.

The hospital has also sponsored several annual health literacy month events that involved community members. Since the conference in October, the hospital has initiated a blog on its website to continue the conversation. St. Vincent is committed to collaboration and partnership and is reaching out to other institutions to broaden its work.

Finally, to illustrate a model of its work, the health literacy team devised a graphic that incorporates five steps to better health literacy (see Figure 3-2). This graphic has been laminated and is posted in every department and in all of the organization’s health care clinics as a daily reminder for health care providers to incorporate these principles in all of their communications.

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FIGURE 3-2 Health literacy 101: Your role as a health care provider to better health literacy.
SOURCE: Komondor, 2013.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

TERRI ANN PARNELL, D.N.P., M.H.A., R.N.

Vice President, Health Literacy and Patient Education North Shore–Long Island Jewish Health System

The following is a summary of the presentation given by Terri Ann Parnell. It is not a transcript.

North Shore–Long Island Jewish Health System (North Shore–LIJ) consists of 16 hospitals with more than 44,000 employees, almost 10,000 nurses, and nearly 10,000 physicians. The system also has 400 ambulatory physician practices, a number of skilled nursing facilities, an ambulatory transport system, a laboratory system, and a research institute. In 2011, it launched a medical school. One of the hospitals is located in the New York City borough of Queens, which is one of the most diverse regions in the world. The populations served by North Shore–LIJ speak more than 176 languages, which offers many opportunities to address health literacy.

North Shore–LIJ leadership makes health literacy integral to its mission, structure, and operations, the first of the 10 attributes of a health litrate organization. In June 2010, the system established the Office of Diversity Inclusion and Health Literacy as a corporate office for all of the system’s facilities—ambulatory, hospital, and long-term care. The chief diversity inclusion officer, Jennifer Mieres, reports directly to the chief executive officer and president, Michael Dowling. Dowling also receives monthly updates on office activities, initiatives, and plans.

The health system has a patient education policy and procedure process, a systemwide patient education committee, and a systemwide language and communication access committee. Beginning in May 2013, the patient education and language and communication access committees will be combined because there are a number of synergies across those subject areas. The system also launched a Diversity, Inclusion and Health Literacy Council with members representing all of its sites. The council’s mission is to share best practices that representatives can modify for their own patient population and for the resources they have available.

The health system is working to integrate health literacy into the various service lines, such as orthopedics, that cut across departments rather than taking a facility-by-facility approach. Parnell said this is intended to integrate a health literate approach across all the system’s hospitals and facilities.

North Shore–LIJ conducted an initial health literacy assessment at several sites for planning purposes. The assessment uncovered many gaps in knowledge and literacy that the health system needed to address. Assessments continue as efforts expand to new hospitals and as demo-

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

graphics change. Health literacy is also integrated into the organization’s annual mandated topics for all employees, as well as new employee orientations, at both corporate and individual site locations.

North Shore–LIJ also monitors its patient experience and HCAHPS scores. There are other health literacy–focused programs that operate throughout the system as well. For example, Patient Safety Fridays is a program in which the organization offers education and training on patient safety every Friday. Often, health literacy or a component of health literacy is the topic. Patient Safety Fridays are for every discipline, from maintenance to security to the executive director’s office. Parnell said that her team has also collaborated with the system quality and informatics departments to help staff with monitoring, compliance, and documentation.

The health system has an onsite training facility called the Center for Learning and Innovation (CLI) that is very helpful in educating and preparing the workforce in health literacy. CLI offers classes and workshops for staff. There is also a Patient Safety Institute, where staff can role-play in different scenarios and obtain feedback on their performance. Some of the lessons learned from these sessions have been incorporated into online modules. The system offers other educational resources, such as toolkits from the Office of Diversity, Inclusion and Health Literacy, monthly tips that go out across the organization, and references to materials and other aids.

One of the early efforts was aimed at raising awareness, addressing cultural competency, and communicating across cultural lines. Sometimes a health care provider does not realize that he or she might be acting in a disrespectful manner. To address this problem, the organization launched the Dignity and Respect Campaign, which was adapted from a program in place at the University of Pittsburgh Medical Center. One of the challenges for this program was convincing people that the initiative involved more than basic courtesy, Parnell said. The campaign includes a video of senior leaders in the organization talking about dignity, respect, and inclusion and their importance to the organization.

The North Shore–LIJ Health System uses a universal precautions approach to health literacy in which one’s health literacy level is never assumed, and the patient is always asked for his or her preferred language. Individual learning needs are assessed, and staff members use plain language and incorporate teach-back methods into communication. The organization also uses the AHRQ Health Literacy Universal Precautions Toolkit and will soon launch a health literacy competency program for nursing staff.

The electronic medical record (EMR) is one strategy used to improve communication at North Shore–LIJ. An effort is under way to include

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

language preference as part of the EMR on the top banner of the record along with allergies and other key information. The hospitals have language-access coordinators at each site. The coordinators receive a daily limited-English-proficient patient report so that they can visit and assess those patients. The coordinators ensure that interpretation services are being used properly, and they confirm understanding by using teach-back methods, which have also been integrated into the EMR. The system also has a language-access audit tool for concurrent monitoring.

Parnell’s team has an ongoing collaboration with the marketing and public relations departments. Collaboration has been productive, and processes are now in place to promote the development of health literate materials. The departmental teams meet and communicate regularly and have developed a process to review the creation and translation of in-house materials. Closed-captioning services are available on all the televisions in inpatient and ambulatory facilities. North Shore–LIJ has also been working with transitional care and patient consent and education documents to improve health literacy in high-risk situations. The health system has completed some projects related to informed consent, medication safety, and the discharge process.

For North Shore–LIJ, interest in health literacy was prompted by the growth of the system and the changing patient population. Senior leadership learned that health literacy strongly correlates with patient safety and patient outcomes. The leadership believes that improving health literacy is an integral part of providing high-quality care, Parnell said. In addition, patient satisfaction scores are tied to value-based purchasing, and the organization is always trying to improve those scores. Also, training new physicians at the medical school brings a different perspective and heightens the awareness of health literacy.

The ongoing support of senior leadership is a key component to continued progress in health literacy. The creation of the corporate Office of Diversity, Inclusion and Health Literacy, which is devoted to enhancing health literacy and providing ongoing education, was also very helpful because the office provides a visible presence, a resource for leadership, and a place to which people needing assistance can be referred. Parnell’s team is also identifying health literacy champions at each of the system’s many sites. People who are passionate about health literacy help drive the process at their organization, she said.

Incorporating health literacy into every system function possible, from internal and external publications to the screensavers that are on the computers in every office and department, also facilitates the spread of health literacy throughout the organization. The hope is that health literacy practices will become automatic behaviors, like hand washing.

Parnell noted that, as she mentioned earlier in her presentation, there

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

is an initiative to move health literacy from an individual facility–based effort to a service-line approach, which will promote sustainability. The organization views health literacy as a necessary service line, just like a clinical service line. It is helpful to tie health literacy to the interests of particular groups, from finance to clinical specialties. The health literacy team always has to make sure the message is meaningful to the audience in order to gain support for its efforts. One way to do this is to ensure that health literacy is incorporated in current work rather than treated as something extra. Standardizing policies, expectations, and accountability across the health system will help continue to move these goals forward.

Comparing the results of the current effort with the baseline assessment is helpful in facilitating and implementing health literacy, according to Parnell. Every year, the health literacy strategy is reexamined to see if it is still relevant to the current situation. It is important to provide to senior leadership a concise but complete overview of what is occurring, because their time is very limited.

One of the key barriers to implementing health literacy efforts is the amount of time it takes. Currently, nurses are the front line of health literacy, but they cannot do everything. Parnell said that she is trying to develop a team approach so that the effort does not rely solely on the nurses. However, getting physician participation can be a challenge.

Another barrier is that no one “owns” health literacy because it applies to everybody. This can lead to everyone thinking health literacy is someone else’s issue. The culture of the system must reinforce the belief that health literacy is everybody’s responsibility and eliminate the assumption that someone else is going to solve the problem.

Parnell said that it is encouraging that her office continues to grow. Ongoing awareness, education, integration, and accountability across the system are essential. She concluded by saying that health literacy is an essential component of excellent patient care.

H. SHONNA YIN, M.D., M.Sc.

Assistant Professor, Department of Pediatrics New York University Langone Medical Center/Bellevue Hospital Center

The following is a summary of the presentation given by H. Shonna Yin. It is not a transcript.

Yin discussed a project aimed at reducing medication errors through the implementation of a health literacy intervention called HELPix. Her presentation focused on local champions engaged in implementing HELPix and the following 8 of 10 attributes of a health literate organization:

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×
  • Has leadership that makes health literacy integral to its mission, structure, and operations.
  • Integrates health literacy into planning, evaluation measures, patient safety, and quality improvement.
  • Prepares the workforce to be health literate and monitors progress.
  • Includes populations served in the design, implementation, and evaluation of health information services.
  • Meets the needs of populations with a range of health literacy skills while avoiding stigmatization.
  • Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact.
  • Designs and distributes print, audiovisual, and social media content that is easy to understand and act on.
  • Addresses health literacy in high-risk situations, including care transitions and communications about medicines.

Two of the main organizations involved in the HELPix initiative were the New York University (NYU) School of Medicine/NYU Langone Medical Center and Bellevue Hospital Center. They are located within a few blocks of each other in New York City. Bellevue is considered to be the flagship hospital of the New York City public hospital system, which is known as the Health and Hospitals Corporation. The families served by Bellevue are largely Latino and of low socioeconomic status.

The HELPix intervention came about as the result of the efforts of two key local champions within the Department of Pediatrics, Yin said. The first champion was Linda van Schaick, an educator in Bellevue’s Pediatric Clinic who founded Bellevue’s Health Education and Literacy for Parents (HELP) project. HELP is a waiting-room intervention designed to support the health literacy needs of parents while they are waiting to see their pediatrician. While van Schaick was developing the HELP project, it became clear to the staff how hard it was for parents to understand how to correctly give medicines to their children, said Yin. In addition, medical providers were struggling with how best to communicate instructions about medicine and did not think they had resources to help families with low health literacy. The second key local champion was Benard Dreyer, the director of pediatrics at Bellevue. He supported the idea of developing an intervention to address the issue of health literacy and parent errors in administering children’s medication.

The intervention was named HELPix because it grew out of the HELP program and involves use of pictograms. As a first step, medication instruction sheets were developed. These sheets are patient-specific, are available in English and Spanish, and use plain language. Pictograms are used to illustrate concepts such as preparation (e.g., shake well), route

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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and frequency of administration, storage, how long to take the medication, and who to call when there are questions (see Figure 3-3).

There is also a medication reminder and tracking sheet, which contains a dosing diagram to help parents know exactly how much medication to give. The prescribed dose is shown within a dosing instrument for liquid medications (see Figure 3-4). The tracking sheet indicates when the medication course should begin and what the total number of doses should be, and it also has a log to help parents keep track of the medica-

image

FIGURE 3-3 Help ix concepts.
SOURCE: Yin, 2013.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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image

FIGURE 3-4 Example of HELPix tracking sheet for as-needed medications.
SOURCE: Yin, 2013.

tions. Providers use this log to talk to parents about specific times that are convenient for the family to give the medicine and to indicate when to start and end the course of medication. Instruction sheets have also been developed for tablets and capsules, as well as for as-needed medications.

Yin explained that the complete HELPix intervention does not involve the instruction sheets alone. HELPix is a five-step intervention. The pictogram-based sheets are the first step and are intended to serve as a framework for providers to use when counseling families about how to

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

give medications. The second step involves the physician showing the parent the dosing diagram and demonstrating how to give the dose using an oral syringe (in the case of a liquid medication). The third step involves the physician using teach-back to make sure that parents demonstrate understanding. Next, the provider reviews with the family the log for tracking medication. For liquid medications, the provider then gives the family an oral syringe to take home. The intervention takes 1 to 2 minutes on average.

A number of partners helped in the development of the HELPix intervention. Feedback from parents was particularly critical, Yin said. Feedback was obtained from both English- and Spanish-speaking families and the HELP program was used as a way to reach potential participants. Many health care providers were also consulted and the New York City Poison Control Center became a key community partner. Overall, there was extensive pilot testing of materials, especially with parents, to find out how well the sheets worked as a whole and how well pictograms and phrases worked individually.

There was recognition of the importance of evaluating HELPix in a rigorous way because evidence showing that the intervention helps improve parents’ ability to follow medication instructions was needed to get the support of hospital leaders and staff. As part of her fellowship, Yin undertook the task of conducting a randomized controlled trial of HELPix in the Bellevue Hospital Pediatric Emergency Department.

English- and Spanish-speaking families with children who were prescribed short-course liquid medicines were enrolled in the trial. Families were randomized to receive the HELPix intervention or standard medication counseling. In terms of dosing accuracy for as-needed medicines, trial results showed that about 40 percent of caregivers who received standard medication counseling made dosing errors compared to about 16 percent of caregivers exposed to the HELPix intervention. For every four families who received the intervention, one family was prevented from making a dosing error. Yin reported that findings with daily dose medicines were even more dramatic, with about 48 percent of caregivers who received standard medication counseling making errors compared to about 5 percent of caregivers who received HELPix. For every two families exposed to HELPix, one was prevented from making an error. In terms of adherence, about 38 percent of caregivers in the control group were found to be nonadherent compared to about 9 percent of intervention caregivers.

The findings were published in the Archives of Pediatrics and Adolescent Medicine. HELPix was also featured as a case study in The Joint Commission’s 2009 publication Addressing Patients’ Health Literacy Needs and received the grand prize at the 2009 Patient Safety and Quality Expo of the New York City public hospital system. This recognition helped garner

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

support for the development of technology that would allow for HELPix dissemination, specifically, a Web application that would give providers the ability to generate medication instruction sheets as part of their routine patient care.

The results of the trial led to support from senior leadership within the NYU Langone Medical Center, including information technology leadership, which made a commitment to create the Web application (see Figure 3-5). Using the Web application, a provider can generate instruction sheets for more than 50 liquid and pill-form medications, with more than 300 variations, for as-needed and daily dose medicines. The instruction sheets are available in English and Spanish. The application sits on the NYU Langone Medical Center server.

Yin said that senior leadership from Bellevue Hospital also agreed to allocate resources to create a link between the stand-alone Web application from NYU and the EMR system at Bellevue Hospital, which is called Quadramed. This link is key to facilitating provider use of HELPix because when providers use the application, patient information can be prepopulated into the HELPix system. This makes the system easier to use, as providers do not need to manually enter patient and medication information into a separate system.

Yin said that her team is currently working closely with providers to encourage them to use the application. Parents are also being encouraged

image

FIGURE 3-5 HELPix Web application, medication instruction sheet.
SOURCE: Yin, 2013.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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through the HELP program to ask their doctors for the instruction sheets. The HELPix team is working closely with the information technology teams at both Bellevue and NYU on troubleshooting challenges that arise during the implementation process.

One of the key parts of the implementation process has been provider training. Several short training modules have been developed to focus on the practical issues of how to generate instruction sheets, how to counsel using the sheets, and how to conduct teach-back. Training has been conducted in groups and in one-on-one sessions, and there are modules available on computers in clinical areas for providers to access at any time.

The goal of the implementation effort is to help providers use HELPix as part of a universal precautions approach to counseling families about medicines. The HELPix implementation process is also being evaluated at two hospitals. As part of the evaluation, they will be examining the effectiveness of HELPix, including whether the use of HELPix improves parent dosing accuracy and adherence and whether HELPix decreases return visit rates. This evaluation is different from the original study, which was done under research conditions in which study staff performed the intervention. The providers are now using HELPix as part of their clinical care, and it is important to evaluate the program’s effectiveness under these conditions.

HELPix began with local champions who recognized that there was a problem and decided to take action. Work on HELPix was also spurred by the growing national focus on health literacy issues. Hospital system support was obtainable because health literacy was recognized to be a patient safety issue that is especially important in the population the system serves, which is composed largely of immigrant families with low socioeconomic status.

Evaluation of HELPix was considered to be a key part of moving the HELPix project forward, because showing the impact of HELPix on dosing errors and adherence was important to getting support for the project from hospital leadership as well as providers. This began with a small quality improvement project, followed by the randomized controlled trial in the emergency department. A pre-/post-implementation study of HELPix is now in progress. Outside grant funding was obtained to support HELP and HELPix-related development, evaluation, implementation, and dissemination. Identifying local provider champions was important for increasing rates of HELPix utilization. Other strategies that facilitated HELPix implementation included establishing the reputation of HELPix through scientific publications and recognition from local and national authorities such as The Joint Commission.

Barriers to HELPix implementation included the amount of time it took to obtain support and resources from senior leadership, particularly

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

with regard to development of HELPix information technology. Initially, the HELPix team thought it would take a few months to obtain support and resources to develop HELPix information technology, but it actually took years. The HELP project began in 2001. The idea for the HELPix instruction sheets was conceived in 2002, and the development of the Web application began in 2007. The work on the EMR link began in 2011, and HELPix was finally implemented at the end of 2012. Competing demands on provider time have been another barrier to implementation.

HELPix will be sustained by the continued commitment of local champions and ongoing support from senior leadership. Much of the infrastructure for HELPix has been built, Yin said, and she anticipates that there will not be too many resources needed to maintain it. There will be a need to continue to identify and obtain commitment from provider champions to encourage HELPix use, as well as a need for continued monitoring and evaluation of HELPix.

Yin said that the next steps include enhancing HELPix technology and functionality. This includes making it easy for users to add/edit medication information as well as new languages. There is also interest in developing instruction sheets for different types of medicines, such as for chronic illnesses, and adapting HELPix for use with adult medications. The team plans to explore further dissemination of HELPix locally, statewide, and nationally.

DISCUSSION

George Isham, M.D. Chair, Roundtable on Health Literacy Moderator

Isham pointed out that Bauer had talked about using MyChart and that earlier in the day McCandless had described how each patient is given a spiral notebook in which important information is recorded so that it can be easily accessed. Isham asked whether the notebook idea could be incorporated in MyChart. Bauer said he thinks the two approaches could coexist very well. Some individuals are technically inclined, whereas others are not, so it is important to have both approaches. He said he hopes the two could eventually be integrated into one system. The Josie King Foundation, for example, has journaling that can be done in written or electronic form, he said.

Kavita Patel, roundtable member, asked Yin if she had thought about marketing and exporting the HELPix system because it is Web-based and vendor-agnostic. In this time of medication adherence problems, it would seem that everyone could benefit from this system, she said. Yin

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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responded that they are very interested in disseminating the HELPix system. The initial approach was to try to develop a stand-alone Web application that could be accessed by everyone in the country. However, such an approach is a real barrier for providers because in addition to writing the prescription in the EMR or on paper, providers would need to log in to the application and create specific sheets. The idea of linking HELPix to the EMR is very exciting, Yin said, but there are so many different EMR systems that it would be difficult to figure out how to do this. She said they are trying to find funds and identify common pathways so that HELPix could be linked to multiple and different EMRs.

Winston Wong, roundtable member, asked about the role of technology in accelerating change. Various speakers touched on this issue with module training, electronic health records, and HELPix form generation. How can technology accelerate and catalyze some of the changes? he asked.

Bauer responded that technology plays a very important role in training and education. How people are trained to maintain their accreditation, for example, has changed significantly over the years with the use of distance learning. A great deal can be learned from how this is done. A lot also can be learned about how to educate people from entities such as the Kahn Academy,4 Bauer said. He believes the concept of “chunk and check” can be applied successfully. For example, rather than a person having to take 3 days off to attend a course, material could be provided online in chunks or segments with feedback scheduled for specific times.

Yin said that she believes technology is important for accelerating change. It is a great way to “hardwire” health literacy into an organization so that providers can easily access health literate instruction sheets for a range of disease processes and issues. One of the difficulties is working within the silo of an organization’s EMR. It would be great if there was a way to share all the promising health literacy work across EMR systems, including items such as revised consent forms, registration forms, and financial forms, she said.

Patel noted that leadership buy-in and timing were themes throughout the presentations. We are now in a time of health care change because of the Patient Protection and Affordable Care Act, she said. The focus is on patient-centered medical homes and accountable care organizations. How could these attributes be thought of in the context of financing delivery system changes? she asked.

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4 The Kahn Academy is a not-for-profit organization “with the goal of changing education for the better by providing a free world-class education for anyone anywhere.” Materials and interactive opportunities are available for free online. See https://www.khanacademy.org/about (accessed June 20, 2013).

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

Bauer said that one impact is on clinic physicians. In the past year, clinic physicians have been making more requests for assistance in health literacy than ever before. It is not uncommon, he said, to get a telephone call from a provider who has concerns about his or a partner’s Clinician and Group CAHPS scores. On the financing side, the ability to reduce preventable readmissions is a driving force. But another major force is that providers are caring people, Bauer said. When they see that patients are not following their treatment plans, they want to know why, and they are pleased to have new tools such as Ask Me 3 and teach-back to help them be more effective.

Parnell said that when health literacy efforts at North Shore–LIJ first started, it was a challenge to get people to ask for help. Now calls for assistance come all the time. Whether the heightened awareness is due to accountable care organizations, value-based purchasing, or worry about readmissions and patient outcomes, the organizational culture is changing. Health literacy is thought of at the beginning of projects rather than at the end.

Komondor added that value-based purchasing and patient experience as reflected in the HCAHPS helped in obtaining leadership buy-in, and the calls for assistance are growing. For example, about 4 or 5 years ago, she said, an attempt was made to promote health literacy in one of the suburban hospitals. The hospital’s comment at that time was, “Oh, we don’t have that problem here. You only have to worry about that downtown.” Since that time, however, the hospital has called for assistance, and health literacy work has begun there.

Ricardo Wray, a participant from the Saint Louis University College for Public Health and Social Justice, asked presenters to speak about the larger policy and regulatory environment. He said it sounds as if these larger forces are encouraging the work being done in health literacy. To what extent does the policy environment facilitate the enhancement of organizational health literacy and to what extent does it hinder such work? he asked.

Parnell responded that the policy environment both facilitates and hinders health literacy work. Regulatory standards encourage health literacy work, but the resources to carry out the work are not always available. Translation of materials into languages other than English, for example, is very costly, and the system is now required to provide vital documents in 18 different languages.

Bauer said that they do not look at regulations as a driver of their efforts because all the work they do is based on what they call the “remarkable patient experience.” The focus is on making sure each person gets what he or she needs. Regulation has probably had some impact on the translator services, but the real driver is the remarkable patient experience, he said.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Yin said that she thinks the policy and regulatory environment is helping rather than hindering because it puts pressure on leadership to make changes. If there is a mandate to disseminate information in specific languages, then that is good leverage to translate instruction sheets into those languages.

Rima Rudd, roundtable member, said that hospital health systems throughout the industry are very concerned about their financial situation and their budget challenges. At the same time, they are being asked to improve quality. Most chief executive officers are looking at return on investments. What are compelling arguments that could be presented to executive leadership to encourage them to implement health literacy programs? she asked.

Parnell said a rationale to present to executive leadership is that health literacy is foundational for patient safety, improved patient outcomes, and patient satisfaction, all of which ultimately tie into reimbursement. Administrators understand the need for patient-centered care.

Komondor said that every hospital is interested in the patient experience as well as meaningful use requirements and readmission rates. Data and examples of how health literacy affects these areas of interest are extremely useful when talking with leadership.

Isham observed that the reduction in readmission rates is a compelling argument for hospitals, given the new Medicare policy.

Wilma Alvarado-Little, roundtable member, said she was interested in learning about language access in the various organizations. How is information or feedback from the non-English-speaking and the deaf and hard-of-hearing communities being captured? she asked. How are those data influencing the organization’s processes and policies?

Parnell said that providing health literate materials in multiple languages and for special populations is a work in progress. Of major importance is educating staff who are the first point of patient contact in the organization. Conversations between registrars and patients can be difficult. Some registrars do not understand that race, ethnicity, and preferred language relate to patient outcomes and patient safety. And sometimes there is pushback from the patient, who says, “You can’t ask me that. It’s illegal.” Some patients think they are going to be treated differently on the basis of their answers.

The organization is looking at a systemwide approach instead of working with one vendor at a time, Parnell said. It is possible that services might need to be provided by region or by several different vendors to meet the language needs of different populations of patients, she noted.

Bauer said they had proceeded in a similar way, educating all the registration staff about how to gather needed information appropriately and sensitively. The organization has hired a director of interpreter and transla-

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

tion services and has formalized a corporate structure for that activity. All staff have been made aware of the services and when and how to use them. All patient surveys are available in English and Spanish. An examination of which other languages might be added is being conducted, Bauer said.

Komondor said that her organization has also trained all of the registrars in health literacy. They are required to attend a training that includes instructions about asking questions on preferred language. The deaf-access coordinator is an active member of the health literacy team, and she conducts health literacy training with the American Sign Language interpreters.

Yin said that when they are training providers about the instruction sheets, they tell them to use the interpreter line for communicating with patients who do not speak English. Currently, the instruction sheets are in English and Spanish only. But they have translated many of the instruction sheets into Chinese, French, Polish, and Russian. The difficulty is incorporating these in the Web application.

Kim Parson, roundtable member, asked Bauer to talk a bit more about financial literacy and explanation of benefits. What mediums are used, when are the conversations held, and how is patient understanding measured? she asked.

Bauer responded that it was a great day when the leader of the organization’s registration process e-mailed him and said he would like to talk about health literacy in the business office. He said he thought they could use the Ask Me 3 approach during registration. A new registration package using best practices in health literacy was launched on April 17, 2013. Many items are in the package because of Joint Commission requirements. But the information is in easy-to-understand terms. For example, all legalese has been eliminated from the financial consent form. Medical terminology has been simplified, as has discussion of insurance coverage. That now moves along the lines of “you have X insurance, which means that you have a deductible of Y, and this is what you need to do, and here is why it is important.” Financial counseling can occur prior to admission by telephone, during the admission process, and as part of the follow-up counseling process.

The process is audited by the patient registration team, Bauer said, but he does not know the measurements used. What he finds impressive is that these people saw health literacy as an opportunity to increase financial literacy. The same kind of thing happened on the legal side, and all forms are now at a fifth-grade reading level with simplified language.

Gemirald Daus, roundtable member, asked Yin if they had considered pictograms and other information that would convey information about medication safety, that is, how home remedies or complementary and alternative medicines might interact harmfully with prescribed medica-

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

tions. Yin responded that there is definitely potential for development in this area. It would be great to be able to tailor messages and include questions about home remedies when generating instruction sheets. At the moment, however, only basic information is given—information parents really need to know to give medications correctly.

Daus said he was pleased to see that North Shore–LIJ had put diversity and health literacy together and asked Parnell to discuss why this was done. Parnell replied that they believed that if health literacy was not included in the name of the department, it might not be recognized as separate from, although related to, culture and diversity. The organization viewed health literacy as an overarching area, with culture and diversity as one of its components. If one cannot communicate and help patients navigate the system, all other components will not work well, she said.

Benard Dreyer, roundtable member, asked whether it is more important to have a separate office for health literacy, or whether it is better to integrate health literacy into patient safety, quality improvement, or regulatory issues.

Komondor said that in her organization there is a separate health literacy committee, but it is composed of people from different disciplines. When they reach out to other hospital committees, such as the patient safety committee, that is where health literacy becomes integrated and institutionalized. And members of the health literacy team sit on virtually every hospital committee, whether it is patient safety or infection control. So health literacy is involved in all ongoing policy revisions and policy developments.

Bauer said he believes there must be a person or group to serve as a focal point and driver for health literacy. However, that person or group cannot be successful without being integrated and inspiring others. Parnell agreed that there must be someone to drive change and be accountable, but if health literacy efforts are not integrated into the system, then nothing is accomplished.

Will Ross, roundtable member, said that health literacy needs to be “hardwired” into the system in order to get provider buy-in. A mature institution understands that health literacy is a key component of corporate culture and embeds it in performance appraisals. But how does one walk the line between embedding health literacy in everything so that it is institutionalized versus highlighting it as a separate and key component? he asked.

Komondor responded that the greatest challenge has been engaging attending providers. Just recently, an attending physicians has agreed to be the physician champion on the health literacy team. What is key, she said, is to have physician-to-physician communication about the importance of health literacy. The attending physician who heads up the

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

residency program has encouraged health literacy efforts and has asked that ongoing health literacy training be added to the curriculum. As a result, medical residents are supportive. It will be a long process, however, to have health literacy fully institutionalized in her medical center, Komondor said.

Bauer said he found that there are early physician adopters and that there are others who are slow to use new techniques. And there are surprises, he said. For example, one physician practice that had strong leadership support refused to adopt Ask Me 3 and teach-back. Although there was a strong physician proponent, there was equally strong resistance from a physician who took the position that communicating with patients was not a problem. In that practice, other staff members were taught to use these tools, and patients are encouraged to use them through wall placements, written material, and videos that play in the office.

Following pilot tests of these techniques in 10 practices, Bauer said he randomly selected four providers and asked if they would share their experiences on video. He conducted documentary-style interviews with each. On the basis of these interviews, a 16-minute video was developed. Its title is What Is the Main Problem, What Do I Need to Do About It, Why Is It Important, and Teach Back. The video is extremely powerful and has resonated with clinicians because it shows their peers being very candid about their experiences, and, in the end, that is what will drive adoption, Bauer said.

Parnell said that there are many physician champions, and they are building support, but currently it is easier to reach the fellows and residents. The chief medical officer of North Shore–LIJ introduces the online module for health literacy and talks about how important it is, and the physicians at the medical school are supportive. Health literacy is gaining momentum, Parnell said, but it will take some time to reach and convince all the attending physicians.

Patrick McGarry, roundtable member, said that he finds it disconcerting that physicians are perceived to be barriers to implementing health literacy. Would health literacy efforts be more palatable if they were couched in terms of patient self-management? he asked.

Bauer said that physicians are not always a barrier. At Novant, physicians were a driving force for establishing health literacy efforts. They can be strong leaders in health literacy. As with any change, however, there are early and late adopters, and this is true of physicians, nurses, and others in medical care.

Isham said that it sounds as if physicians can be a barrier or they can be an asset. When physicians are a barrier, there are special challenges if the person attempting to implement health literacy efforts is not a physician.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
×

Yin said that physicians work within a system. If the system is not conducive to practicing in a health literate manner, then it is not just the physician who is the problem, it is also the system, she said.

Cindy Brach, roundtable member, said that one of the things that concerns her is that even with the use of health literacy tools such as Ask Me 3 and teach-back, there may not actually be shared decision making about treatment plans. She asked whether shared decision making is part of health literacy. She also asked Bauer to describe how he measures whether shared decision making takes place.

Bauer responded that when a patient is educated, he or she is able to be part of a conversation. Encouraging questions and joint decisions is part of that conversation, and health literacy techniques such as Ask Me 3 facilitate the conversation. Patient-centered care is the goal, and talking about the diagnosis and treatment options and jointly arriving at a decision about the best way to proceed is what we strive for. When that approach is used, measures of patient satisfaction increase.

Komondor said that shared decision making depends, to some extent, on the population with which one is working. All staff members have been trained to encourage patients to ask questions, to become involved in their own care, and to share in decision making. A short time ago, Komondor said, she conducted a focus group with some women in the community who were asked about their struggles with health and getting health information. The main thing she learned was that the women were too intimidated to ask questions. They said things like “The doctor doesn’t have time,” or “We don’t want to appear stupid,” or they figured the doctor would tell them what they needed to know, and if they didn’t understand, the doctor would tell them again at the next visit. This kind of population presents a huge challenge to shared decision making.

Andrew Pleasant, roundtable member, said that although the presenters had described cost as a barrier to implementation, no one had included an assessment of cost savings associated with the interventions implemented. Was that because the assessment has not been done, or no effect was found, or because it was impossible to tease out the effect of health literacy from other factors? he asked.

Bauer said that they saw a large decrease in readmissions for congestive heart failure after health literacy efforts were implemented. But, he added, it is very difficult to show that health literacy was the driving factor, given the many variables involved. Parnell agreed that isolating the impact of health literacy from other factors is very difficult.

Isham observed that when implementing programs in real-world systems as opposed to a research trial, it is difficult to identify what is responsible for change. It would be helpful to learn about methods that can be used to evaluate impact in such situations. Are there more robust

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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analytic abilities within the systems that can help with a complex evaluation? he asked.

Parnell responded that they have a research institute that helps with evaluation. Komondor said her organization does not have help, but they have set a major goal to measure outcomes. They would, she said, appreciate input on how to do this. Bauer said Novant has a very sophisticated evaluation department, but the question is complicated and they have not yet taken the time to address it fully.

REFERENCES

Bauer, T. The Novant Health journey in addressing health literacy. 2013. Powerpoint presentation, Institute of Medicine Workshop on Organizational Change to Improve Health Literacy, Washington, DC, April 11.

Brach, C., D. Keller, L. M. Hernandez, C. Bauer, R. Parker, B. Dreyer, P. Schyve, A. J. Lemerise, and D. Schillinger. 2012. Ten attributes of health literate health care organizations. Discussion Paper, Institute of Medicine, Washington, DC. http://www.iom.edu/Global/Perspectives/HealthLitAttributes.aspx (accessed September 7, 2013).

Komondor, K. 2013. Health literacy journey at St. Vincent Medical Center. Powerpoint presentation, Institute of Medicine Workshop on Organizational Change to Improve Health Literacy, Washington, DC, April 11.

Yin, S. 2013. Reducing parent medication errors: Implementation of the HELPix intervention within a NYC hospital setting. Powerpoint presentation, Institute of Medicine Workshop on Organizational Change to Improve Health Literacy, Washington, DC, April 11.

Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Suggested Citation:"3 Panel 2: Implementing Attributes of a Health Literate Organization." Institute of Medicine. 2013. Organizational Change to Improve Health Literacy: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18378.
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Organizational Change to Improve Health Literacy is the summary of a workshop convened in April 2013 by the Institute of Medicine Board on Population Health and Public Health Practice Roundtable on Health Literacy. As a follow up to the 2012 discussion paper Ten Attributes of a Health Literate Health Care Organization, participants met to examine what is known about implementation of the attributes of a health literate health care organization and to create a network of health literacy implementers who can share information about health literacy innovations and problem solving. This report discusses implementation approaches and shares tools that could be used in implementing specific literacy strategies.

Although health literacy is commonly defined as an individual trait, there is a growing appreciation that health literacy does not depend on the skills of individuals alone. Health literacy is the product of the interaction between individuals' capacities and the health literacy-related demands and complexities of the health care system. System changes are needed to better align health care demands with the public's skills and abilities. Organizational Change to Improve Health Literacy focuses on changes that could be made to achieve this goal.

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