For best results, create systemwide plan for overcoming literacy barriers

Organized committee tackles specific projects along the lines of members' expertise

Barriers to health literacy are best addressed if a systemwide plan is initiated, says Kimberly Wicklund, MPH, manager of health information & promotion at Group Health Cooperative in Seattle.

"If you don't address health literacy needs in a formal way, you will get pockets of change - but not systematic change," she explains.

What has worked at this health care institution is a network of diverse disciplines, representing such departments as health information, communications and community relations, continuing medical education, patient safety, pharmacy, web services, and health studies and interpretative services. They are called the Group Health Plain Language Network.

Wicklund says when she arrived at Group Health three years ago, she found that the people in her department were interested in a more proactive approach to health literacy but worked only within their sphere of influence, which was patient education.

To advance the process, Wicklund set up a workshop for her staff on health literacy, taught by an expert, and opened it to other departments, as well. As a result, about 20 additional people interested in health literacy attended. At the workshop, they realized that by working on health literacy within departments, they were duplicating efforts.

"It made sense for us to come together and do some information sharing and collaboration, for we were all working in our silos and reinventing the wheel. We had our first meeting in late 2006," says Wicklund.

Collaboration is the key to addressing health literacy issues systemwide, agrees Nadia Ali, MD, MB;BS, an academic internist with the University of Pennsylvania Health System in Philadelphia.

The Health Literacy Task Force at Pennsylvania Hospital was formed after Ali presented the results of a survey she conducted assessing barriers to health literacy focusing on printed health information given to patients. She gave the findings to the interns, residents, and nurses surveyed, as well as department heads and committees linked to the issues identified, such as the patient and family education committee.

The presentation of the findings helped Ali identify those who were interested in analyzing and addressing the issues, and a group of individuals from different clinical departments were invited to formally come together as a task force.

"The members of the task force also act as liaisons between the different departments and committees," says Ali.

Although both health care institutions are addressing health literacy, their methods differ, shaped by their unique circumstances. At Group Health, there were no extra resources to do the work, and staff members needed to justify the time spent on projects and meetings, according to Wicklund. Therefore, it was determined that the group would meet only quarterly. However, a listserv keeps them connected and allows others who are interested - but do not want to be involved in active work - to be included in the information sharing. The network has diverse representation across the organization.

Working groups are organized when a collaborative project is identified. People from the network are pulled into work groups that meet more regularly if the work is relative to their expertise. Those on the listserv who are not active often identify beneficial connections and advocate for health literacy.

Pinpoint projects

In the beginning, the Group Health Plain Language Network decided its reason for coming together to collaborate on health literacy was to create a plain language communication culture at Group Health.

Wicklund said the network determined it was important not only to identify the problem, but also the solution, so people could see what their role is when addressing the problem.

"Saying 'we will all use plain language in our communication with patients' is very solution-oriented. People understand it, because they see the kind of information patients get, and they see they can improve it. We planned it that way very strategically and set our goal as trying to promote a plain language communication culture," says Wicklund.

Projects completed at Group Health

Projects completed or in progress at Group Health include a toolkit posted on the Intranet that helps people understand how to use plain language. It has a comprehensive alternative word list, and suggestions for communicating orally in plain language and communicating in writing with plain language. It also has before and after examples of plain language.

A lot of information distributed by Group Health has been edited, such as a letter sent to patients from the lab that resulted in calls for clarification, because the language was confusing. All diabetes resources were revamped, as well. The material was in the form of a book but is now in a modular format, so patients are only given information that is relevant to them at the moment, and it is written in plain language.

Information on the Web site is now written in plain language, and a few nurses were trained to do presentations on health literacy throughout the organization. Currently, the group is in the process of editing the general surgery consent forms. The new forms, written at a fifth grade level, are being reviewed by surgeons and legal experts. Patients will be shown the completed form, as well.

"A lot of our accomplishments have been around communication and editing," says Wicklund.

Pennsylvania Hospital initiatives

The Health Literacy Task Force at Pennsylvania Hospital identifies barriers to health literacy and comes up with recommendations to address them, says Ali. For example, a new medication form was created, because available patient information is usually extensive, with readability levels above the fifth-grade, says Ali. Frequently, the authors use medical jargon.

"The form is very simple and brief, yet it assures that all-important aspects pertinent to a new medication are covered. Teach-back technique can be used once the form is filled out by the provider with the patient," says Ali. (The form can be viewed at

People on the task force who have an intense interest and expertise on a topic are usually selected to do the work on a project. For example, a standardized needs assessment form is being written by two nurses with help from Ali. Once completed, all work goes to the task force for review.

Other projects in progress include the redesign of a patient admission brochure and organizing a group of lay people to evaluate the forms being used in the hospital. A web site with written health information designed for patients with low health literacy was created, and health providers are being encouraged to use it (

There are many organizations and resources that help committees address health literacy, says Wicklund - for example, the Minnesota Alliance for Patient Safety, which developed a statewide consent form. She used information from such resources when writing a charter for the official initiative. The Plain Language Initiative was formalized in October 2007 to coincide with health literacy month.