Joint Commission focuses low health literacy issues

Communication gap addressed

When The Joint Commission released information on how to narrow the communication gap between patients and health care practitioners to improve patient safety, some people in the field of patient education said, "It's about time."

That's because The Joint Commission finally put muscle behind educational strategies patient education managers have been trying to make common practice for years.

"It's like the 200-pound gorilla speaks. When accreditation bodies take on these kinds of initiatives the health care systems start to take notice, and they put in place processes to make sure it happens," says Sandra Cornett, PhD, RN, director of the OSU/AHEC Health Literacy Program at The Ohio State University in Columbus.

"JCAHO is a key driver for our organizational change and priority setting," says Cezanne Garcia, MPH, CHES, associate director for patient- & family-centered care and education services at the University of Washington Medical Center in Seattle. Therefore, she expects good communication practices to become more commonplace.

For example, one established communication method specifically highlighted by The Joint Commission is "teach back," a technique that is very familiar to patient education managers.

Teach back is the best and easiest way to evaluate understanding, says Fran London, MS, RN, a health education specialist at The Emily Center at Phoenix (AZ) Children's Hospital. Using the teach back method, for evaluating understanding of the information taught, health care practitioners ask patients how they would explain a procedure, treatment, or self-management skill to their spouse or mother.

"It's time to get back to basics with patient education and realize the intent of patient education is to equip patients and families to be able to participate in informed consent and decision making; participate in their care and decisions; know how to care for themselves at home; and know when and how to call their health care provider," says Kathy Ordelt, RN-CPN, CRRN, patient and family education coordinator at Children's Healthcare of Atlanta.

Health care institutions have responded favorably to many issues The Joint Commission has pushed, such as hand washing, says London. "It's hard to argue against communication. However, it is a much more complex skill than hand washing and will need more attention to get results," she adds.

The Joint Commission plans to give it the attention. During the news conference, Dennis S. O'Leary, MD, president of The Joint Commission, said the national patient safety goals and related requirements, such as medication reconciliation, relate to the communication issues in the white paper. However, the way in which the requirements are framed do not draw explicit attention to the issue of low health literacy; therefore, The Joint Commission would look at reframing the requirements.

He also stated there is a table in the paper that focuses on how to implement patient safety goal requirements in a health literacy context.

"Helping practitioners recognize health literacy problems begins with providing them with an awareness of the problem. Many practitioners really don't know much about health literacy and how it impacts health outcomes," says Cornett.

Therefore, Cornett first provides a basic explanation of low health literacy before teaching practitioners the clues to look for and questions to ask to determine if there is a communication problem.

She says the use of case studies is a good way to get the key points across as well as showing videos on low health literacy. She has written a handout that includes clues to look for and questions to ask to assess a patient's ability to read.

Some of the clues to watch for include a patient listening or watching attentively to try to memorize information or having difficulty following directions.

Questions to broach the subject of reading problems may include:

  • Do you like to read? How often do you read?
  • Medical terms are complicated and many people find the words difficult to understand. Do you ever get help from others in filling out forms, reading prescription labels, insurance forms, and health education sheets?
  • A lot of people have trouble reading and remembering health information because it is difficult. Is this ever a problem with you?
  • When you have to learn something new or unfamiliar to you, what ways do you prefer to learn the information? Do you like to read, watch TV or videotape, listen to tapes or CDs, use the computer, talk to other people, or practice how to do something?

Communication methods such as "teach back" need to be a part of staff education programs and included in orientations, in-services, continuing education programs, or self-directed learning modules.

"If every program on a clinical topic had a section on not only what patients should be taught but also how to teach it we would be further ahead in establishing a norm for patient communication methods," says Cornett.

London agrees, "Skills such as the 'teach back' method may not be part of the education health care professionals receive. It is not a skill incorporated early in training," she says.

To make sure patients understand what is being taught, patient care pathways or patient education plans used by staff need to reflect some of the methods for clear communication. In addition, policies and procedures for patient education and patient-centered initiatives need to have communication methods spelled out, says Cornett.

For example, at The Ohio State University Medical Center, the guidelines for creating teaching tools state "ideas on how to implement the educational plan and teach the content" are to be included.

Also staff competencies in effective patient communication methods need to be written into job descriptions and performance appraisal systems and evaluated with other clinical competencies.

When included as part of staff competencies, effective patient communication methods then become a staff expectation in giving care and the message that "it is valued" is sent to staff, says Cornett.

While many of the recommendations for clear communication made by The Joint Commission seem to be core patient education strategies, they have not become a common part of health care practices because the "system" has not held the practitioner accountable for these practices and often the support for the staff to implement the strategies is nonexistent, says Cornett.

"We set up practitioners for failure because we expect unrealistic results in a fast-paced, highly emotive environment when patients are least likely to be able to learn. Patient education managers need to help practitioners better prioritize what is needed and choose realistic ways to accomplish the patient education," explains Cornett.