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“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
20
Currently, there are no nationally recognized
standards for the training of medical interpreters.
Therefore, health care organizations are often
left to set their own expectations for interpreter
competency, or to rely on local or national training
organizations. This has resulted in a national pool
of medical interpreters who have inconsistent skills
and qualifications. At the most basic level, organiza-
tions should have some mechanism for evaluating
an individual’s bilingual language proficiency.
However, medical interpretation is a skill that
requires more than language proficiency.
Professional medical interpretation training pro-
grams should have curricula that include a basic
clinical orientation that addresses anatomy and
common illnesses and procedures; interpreter skills,
such as managing communication flow; general
language and medical terminology; legal and
ethical issues; reading comprehension; and cultural
competence training.
52
Guidance on setting per-
formance and training expectations for medical
interpreters is available from the National Council
on Interpreting in Healthcare, www.ncihc.org.
It may not be practical or economically feasible
to always have in-person interpretation, given the
range of languages and dialects that are represented
in many communities. For languages other than
those primarily spoken in the community, many
health care organizations rely on interpreter
telephone services, often called “language lines.”
As with in-person interpretation, the skills and
training of the phone interpreters deserves careful
scrutiny. Staff should also be trained on whom
and how to call for language line services. Any
devices needed to facilitate telephonic interpreta-
tion, such as hands-free headsets and dual hand-set
telephones, should be readily available.
Culture Clash
Language barriers are not the only obstacle to
health literacy and effective communication.
Culture clashes can erode trust between caregivers
and patients and their families and impede effective
communication. When it was explained to Lia’s
father that she would likely die within hours of
being removed from life-sustaining equipment, his
impulse was to grab her and run, which is what
he did.
53
In Hmong culture, it is deeply offensive
and threatening to predict the death of someone.
54
Similarly, when a Spanish-speaking interpreter
was asked to tell a Mexican mother that her child
would die overnight and there was no more hope,
the interpreter refused because “you never tell a
mother in our culture to give up hope.”
55
To encourage “cultural competency” among health
professionals, the Office of Minority Health estab-
lished the Culturally and Linguistically Appropriate
Services (CLAS) Standards. The Joint Commission
accreditation standards complement and echo the
CLAS standards. Both the CLAS standards and
those of The Joint Commission recognize that
culturally and linguistically appropriate services are
essential to safe, high-quality care. However,
existing standards may not be sufficient. To raise
the bar further, the Joint Commission, with funding
from the California Endowment, is currently study-
ing the extent to which hospitals are providing cul-
turally and linguistically competent care. Hospitals,
Language and Culture is a three-year project to
gather data from a sample of hospitals to assess
the challenges they face, and their capacity to
address the issues of language and culture that
impact the quality and safety of care they provide.
The information gained from this study will be
used to set realistic expectations for culturally
competent care in the future.
90
21
“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
Preliminary results from the study reveal that while
health professionals truly wish to do right by all of
their patients, there is a general lack of awareness
of the CLAS standards as well as the relevant Joint
Commission standards.
56
Therefore, compliance
with either standard set is inconsistent.
57
Despite
recent regulatory efforts, there is also a lack of
awareness of the pitfalls of using family members,
even children, as interpreters instead of trained
interpreters.
58
According to the Health Research and Educational
Trust, 52 percent of hospitals report that they collect
information on patients’ primary language to
include in their medical records.
59
Only 20 percent
collect information about patients’ literacy levels.
60
To raise these rates and to improve care for patients
across the continuum of care, The Joint Commission
has implemented a new requirement that accredited
organizations document the patient’s language and
communication needs in the medical record. This
requirement emphasizes that language and commu-
nication needs are a vital piece of demographic as
well as clinical information.
Patient-Centered Places
“Mother states she went to MCMC [Merced
Community Medical Center] as scheduled for
blood test, but without interpreter was unable
to explain reason for being there and could not
locate the lab. Is willing to have another appt.
rescheduled….Mother states she feels intimidated
by MCMC complex but is willing to continue treat-
ment there.” This notation in Lia Lee’s county
health department record unwittingly describes
what so many who have limited literacy or English
proficiency experience. Entering a hospital can be
like entering another world. Interpreting naviga-
tional signs – even getting past the front desk – can
be too difficult. Creating an environment that wel-
comes all individuals for the provision of safe, high-
quality care is every health care leader’s obligation.
Proposed additions to Joint Commission standards
would require the leadership of an accredited
organization to maintain a culture of quality and
safety. For accredited hospitals, the leaders would
be expected to assess the hospital’s safety and
quality culture using a valid and reliable evaluation
tool, such as the survey instrument developed by
the Agency for Healthcare Research and Quality
(AHRQ).
61
Introduced in 2006, the AHRQ Hospital
Survey on Patient Safety Culture will allow hospitals
to compare their patient safety culture survey
results with those of other hospitals, and to identify
areas for improvement.
62
New Joint Commission
standards further require leaders to define how
members of the population served can participate
in the management of safety and quality issues
within the hospital. Among the key systems
critical to safety and quality for which leaders
must provide stewardship is communications.
In a recent study of hospital executives’ awareness
levels respecting health literacy, 65 percent said
they were aware of the link between low health
literacy and medical error; however, only 25 percent
rated the issue as a priority that needed to be
addressed in their organizations.
63
Given the
prevalence of literacy issues, this gap between
perception and what is the more likely reality will
need to be narrowed.
Several initiatives are underway to determine
best practices in patient-centered communications.
These are defined as communication that is
respectful of and responsive to a health care
user’s needs, beliefs, values and preferences.
64
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“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
22
The American Medical Association’s (AMA) Ethical
Forces Program has developed criteria for health
care organizations to use in assessing their perform-
ance related to patient-centered communications.
Among the areas addressed by this Patient-Centered
Communication Framework are organizational com-
mitment – the extent to which leadership, staff and
resources are committed to the mission of patient-
centered communications; community outreach
efforts; workforce composition and training; the
engagement of patients, with particular attention to
respect for socio-cultural diversity; provision of lan-
guage assistance services; consideration of health
literacy and use of clear communication; and
application of quality improvement concepts.
65
The
AMA Ethical Forces Program has also initiated a
hospital recognition project to raise awareness of
innovative approaches to patient-centered commu-
nications and to reward hospitals that are leading
the way in these efforts.
One organization recognized by the AMA program
is the Iowa Health System (IHS). The IHS Health
Literacy Collaborative was launched in 2003 to
improve the quality of care provided to all patients
and their families by raising awareness of health lit-
eracy issues and developing effective strategies for
enhancing communications throughout its health
system.
66
To meet the goals of the collaborative,
key partnerships were identified that included the
New Readers of Iowa – adult learners who advise
health system staff on the readability of their mate-
rials for people who struggle with reading – as well
as patients and families, medical and pharmacy
societies, and the department of public health.
The scope of the collaborative included inpatient
and outpatient settings, as well as support services,
such as transportation, and home health and call
centers. In addition to addressing health literacy
issues in care delivery, the collaborative piloted
improvements in navigational aids.
The IHS project also recreated informed consent
forms by adjusting reading levels from collegiate to
sixth- and seventh-grade levels, and promoted the
Partnership for Clear Health Communication’s Ask
Me 3 campaign across health delivery settings.
67
Ask Me 3 – through posters, brochures and buttons
– encourages patients to ask their health care
providers these three key questions: What is my
main problem? What do I need to do? Why is it
important for me to do this?
68
The Health Literacy Collaborative also utilized the
“teach-back” methodology. “Teach back” entails
asking the patient to repeat – or teach back – to
the treating clinician the important health care infor-
mation that has been communicated in the health
care encounter to assess and ensure the patient’s
understanding. The AMA makes a tool kit available
that educates health care professionals on the
“teach back” method. “Teach back” is also includ-
ed among the National Quality Forum’s Safe
Practices. The AMA tool kit also encourages physi-
cians to speak more slowly with patients and to use
plain language. Whenever possible, physicians
should show models or actual devices, or draw pic-
tures. Information should be limited to the two or
three main things that patients need to know per
visit, and be repeated during the visit. Patients
should always be made to feel comfortable asking
questions in a “shame-free” environment.
69
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“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
The Collaborative’s tactics heavily emphasize staff
education and training. Among the lessons learned
is that “administrative leadership is key,” and
engagement of patients and families is fundamental
to successful strategies.
70
The Collaborative also
found that individuals who struggle with literacy
are often patients, but they may also be health
system staff.
71
Inside and Out
Health care organizations should know the commu-
nities they serve – not simply the primary ethnic
groups and languages that are represented, but the
general literacy level of the community as well.
An interactive tool for determining state, county,
town, and even subdivision literacy levels is avail-
able at www.casas.org/lit/litcode/search.cfm. While
this tool currently relies on 1990 U.S. Census data,
plans are underway to update the tool once the
requested microdata from the 2003 National
Assessment of Adult Literacy are available.
In the 2001 Commonwealth Fund Health Care
Quality Survey, substantially higher rates of blacks,
Hispanics and Asians reported having “communica-
tion problems with their physicians” than did white
patients. Further, twice as many blacks as whites
(16% vs. 9%) reported being treated with disrespect
during a health care visit.
72
Not surprisingly, race
concordance between patients and their physicians
has a positive effect on communications and
patients’ perceptions of the quality of their care.
73
In a recent study, physicians in race-concordant
encounters spent more time – 2.2 minutes – with
their patients, were rated as “more participatory”
and engaging of the patient, and received higher
patient satisfaction ratings than physicians in
race-discordant medical encounters.
74
The 2002 IOM report, Unequal Treatment, made
clear that distinct disparities exist both with respect
to access to care and to the quality of health care
for racial and ethnic minorities, regardless of their
insurance status or ability to pay.
75
The study of
race-concordant medical encounters underscores
the importance of increasing diversity among health
professionals, as called for by the IOM. However,
it also highlights the central role that effective
communications can have on engendering trust
and building relationships among patients and
physicians of different races.
76
The focus on the quality of communications
and racial and ethnic status becomes even more
important in light of the prevalence of health
literacy issues among specific groups. Those with
literacy issues come from all walks of life; however,
educational level, nativity, socio-economic status,
and elderly age are all potential indices of low
health literacy.
43
“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
24
Solutions to Make Effective Communications An
Organizational Priority to Protect the Safety of Patients:
• Raise awareness throughout the organization of the
impact of health literacy and English proficiency on
patient safety.
• Train all staff in the organization to recognize and
respond appropriately to patients with literacy and
language needs.
• Create patient-centered environments that stress the
use of clear communications in all interactions –
from the reception desk to discharge planning –
with patients.
• Modify strategies for compliance with The Joint
Commission’s National Patient Safety Goals to
accommodate patients with special literacy and lan-
guage needs.
• Use well-trained medical interpreters for patients
with low English proficiency.
• Provide reimbursement to cover health care organi-
zation costs for providing trained interpreters.
• Create organization cultures of safety and quality that
value patient-centered communications as an integral
component of delivering patient-centered care.
• Assess the organization’s patient safety culture using
a valid and reliable assessment tool, such as the
AHRQ Hospital Survey on Patient Safety Culture.
Administrative and Clinical Leaders, Patient
Safety Directors
Administrative Leaders, Patient Safety Officers,
Social Services, In-Service Educators
Administrative Leaders, Department Heads,
Social Services
Administrative and Clinical Leaders, Patient
Safety Officers
Administrative Leaders, Department Heads,
Social Services
CMS, State Medicaid Agencies, Private Payers
Administrative and Clinical Leaders
Administrative and Clinical Leaders
Tactics
Accountability
24
25
“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
• Assess the organization’s stewardship and accultura-
tion of patient-centered communications, such as
through the AMA’s Patient-Centered Communication
Framework.
• Become knowledgeable about the literacy levels
and language needs represented by the community
served.
• Make cultural competence a priority, as demonstrat-
ed by hiring practices that value diversity and the
continuing education of the staff.
• Pursue a research agenda to expand understanding
of the impact that communication issues have on
patient safety, disparities in health care, and access
to care.
Administrative and Clinical Leaders, Patient
Safety Officer
Administrative and Clinical Leaders, Clinical
Staff, Social Services, Patient Advocates
Administrative and Clinical Leaders
Foundations, Health Care Researchers
Tactics
Accountability
71
“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
26
The Yellow Baby
Jose Cruz, the son of an immigrant mother, was
born in this country. At discharge from the hospi-
tal, minimal jaundice was observed by the medical
team and his mother was told to seek follow-up
care at a local community health center. When he
was ten-days old, his mother dutifully sought such
medical attention for Jose. At that visit, it was
decided that Jose would need a lab test to deter-
mine whether blood incompatibility was the source
of his jaundice. Because Jose was an American
citizen, he was eligible for the Medicaid insurance
for which his mother was ineligible. But that
would take time and patience to acquire, time that
neither Jose nor Mrs. Cruz had. The doctor there-
fore decided to allow the clinic to cover the cost of
the lab test. The test showed elevated but not dan-
gerous bilirubin levels. Mrs. Cruz was scheduled to
bring Jose back to see the doctor in one week, but
was told to bring the baby back at once if his color
should become more yellow and he was not feed-
ing well. Five days later, Jose presented “basically
D.O.A.” at the clinic’s door.
The doctor’s first thought was that Mrs. Cruz had
ignored his instructions to monitor the baby. But
she had not. Worried that Jose was becoming sick-
er, she had brought him back to the clinic just as
the doctor had instructed. The clinic, always busy,
was especially busy that day. When she expressed
her concerns about the baby to the clinic recep-
tionist – through the interpretation services provid-
ed by another mother in the waiting room – the
receptionist said that the doctor was too busy to
see Jose and that since she had an appointment in
a few days anyway, she should bring him back
then. Feeling helpless, Mrs. Cruz brought Jose
home where she applied a native remedy – a
“healing band-aid” – to his abdomen and tried to
feed him rice water. When Jose’s cry became very
quiet, Mrs. Cruz returned to the clinic with him.
This time, she told the receptionist that she thought
Jose was dying. This time, the receptionist let her
through. Only it was too late.
This sad tale of a mother and her infant son, para-
phrased from the story written by Fitzhugh Mullan
in Health Affairs, is fiction. But could it be true?
Has it been true in some ways in some places in
this country? The story illustrates the threat that a
bureaucratic, insensitive system poses for patient
safety, especially for those who cannot forcefully
advocate for themselves.
Step One in the Continuum: Entry
The Welcoming
For people with low literacy skills, navigating the
health system is a nightmare. Deciphering hospital
signage – “cardiac catheterization laboratory and
outpatient radiology this way;” completing complex
forms; interacting with physicians; following med-
ication instructions; and coping with real or per-
ceived slights from hospital personnel place high
demands on those with low literacy skills.
77
For
some, these demands are too high and they simply
avoid health care, to the detriment of their health.
One woman put it this way: “I’ve had a lot of
II. Incorporate Strategies to Address
Patients’ Communication Needs Across
The Continuum of Care
79
27
“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
Deciphering hospital signage – “cardiac catheterization laboratory and outpatient
radiology this way;”completing complex forms;interacting with physicians;following
medication instructions;and coping with real or perceived slights from hospital
personnel place high demands on those with low literacy skills.
illnesses, but I preferred to stay home, until I get
better by taking anything I can. Because being
asked to fill this out, to fill that out, I feel embar-
rassed to ask for help, to ask them to fill them out
for me. They might get upset or they would say,
‘This lazy lady, she never learned to read,’ that’s
how I think.”
78
For others, it is not a matter of choosing not to go;
it is a matter of not understanding when to go. The
very first step in the continuum of health care is rec-
ognizing the need to seek care or to pursue preven-
tive health strategies. Recognizing potential symp-
toms and knowing when to go to the doctor are
more challenging for those with low health literacy,
who are also known to experience poorer health
outcomes.
79
People with low health literacy may
delay seeking care, and suffer prolonged symptoms.
In one study, men who presented for care with
late-stage prostate cancer were found to have
lower reading levels than those who presented
with early-stage cancer.
80
The study authors suggest
that disseminating culturally sensitive educational
materials that reflect literacy levels in the community
served can raise awareness of prostate cancer and
promote early identification of symptoms.
81
Once the need for care is recognized, the barriers
to entry into the health system – whether getting
the requisite clearance from a private or public
payer, or dealing with gatekeepers, such as recep-
tionists and admissions clerks, at the point of entry
– can be overwhelming for anyone, but especially
for those who are vulnerable.
A major barrier to entry into the health system is
obviously lack of insurance. People with low
health literacy, who are also more likely to have
low income, are at greatest risk of being
uninsured.
82
Those who may be eligible for
Medicaid, or whose children may be eligible under
the State Children’s Health Insurance Program
(SCHIP), may not pursue benefits because the task
of applying is too onerous.
83
In one study, 100
percent of enrollees with low literacy levels did not
understand the rights and responsibilities section of
the Medicaid application, compared to 93.7 percent
with marginal health literacy, and 17.3 percent with
adequate health literacy.
84
Typical public benefit
forms, like other health-related materials, are writ-
ten at the 10th grade level of understanding and
above.
85
Application forms are usually several
pages long, have dense copy and are complicated
– more than intimidating enough to turn potential
applicants away or confuse them.
To help state governments improve the approacha-
bility and readability of their program materials,
the Robert Wood Johnson Foundation funded the
development of the Health Literacy Style Manual.
86
This style manual provides guidance on how
to turn an application for benefits into a “visual
75
“What Did the Doctor Say?:” Improving Health Literacy to Protect Patient Safety
28
invitation,” among other tips for improving commu-
nications with the intended audience.
87
The goal of
the manual is to improve state program communi-
cations by using “client-centered communications”
that will elevate the health literacy of the insured
population.
88
In turn, improved health literacy will
result in better use of benefits, better outcomes,
and reduced costs. For instance, beneficiaries may
take more advantage of well-baby care before
delivery; take children in for check-ups; and use
emergency departments much less often.
89
The Public Good
Health literacy is a factor in engaging patients in
preventive care as well. In fact, improving health
literacy is a goal set by Healthy People 2010, the
federal government’s public health report that lays
out the nation’s health objectives for the first
decade of the 21st century. Key to achieving
this goal – as well as improving the overall health
status of the American public – are effective
communications and the coordination of such
communications, resource allocations and tactics
among public health officials, individual practition-
ers, and health care organizations.
According to the Healthy People 2010 report, for
health communications to be effective, they must
be “audience-centered” – that is, the communica-
tion activities must reflect audiences’ preferred for-
mats, media and contexts.
90
This is especially
important in reaching diverse racial and ethnic
populations.
91
The concept of “patient-centered
communications” is applicable as well to communi-
cations meant for broad audiences of potential
patients. Putting information – conveyed in plain
language – in the context of peoples’ lives, so
that they can identify with and apply it, is equally
important in a television or radio broadcast as it
is in a one-to-one exchange.
In research undertaken at the University of
Michigan’s Center for Health Communication
Research, researchers tested the effectiveness of
public health messages meant to change behavior.
The messages that were most effective were those
that framed health advice in a personal context for
the audience. Where public health campaigns typi-
cally target an audience, say African-Americans, the
University of Michigan work revealed that tailoring,
not targeting, is the more effective strategy. For
instance, many African-Americans have little in
common – as in the span of difference between
Condoleeza Rice and Snoop Dogg, for instance.
92
An elderly man may not respond to an admonition
to stop smoking because he may die from it, but he
may respond to a plea to stop when it is linked to
something else in his life he highly values, such as
being at his grandson’s wedding.
To decipher individual differences, participants
were invited to engage in an interactive, Web-based
program that elicited personal health and lifestyle
information. This information was then used to
Putting information – conveyed in plain language – in the context of peoples’
lives,so that they can identify with and apply it, is equally important in a television
or radio broadcast as it is in a one-to-one exchange.
Documents you may be interested
Documents you may be interested
