Health system grades patient educators

300 observers and coaches are involved

The people at Iowa Health System in Des Moines knew they had good patient education methods. They’d been using teach-back for years, through which patients are never asked yes or no questions like “Do you understand the instructions?” but are instead asked to repeat back their understanding of what was said by a provider.

But how do you know how well providers are doing it? “How do you make sure you have educated your staff to use it all the time?” asks Deb Shriver, RN, MSN, chief nurse executive at Trinity Regional Medical Center in Fort Dodge. “You can talk about it, but you really have to keep talking about it all the time.” They have instituted an observational protocol where caregivers are observed doing patient education, and then evaluated and coached if necessary. They are all asked about any barriers they have to using the method. “Time is one thing. It takes longer,” Shriver says.

The concept has been around for a while, says Denise Cundy, MS, RN, a nurse manager on the North 6 unit at Iowa Methodist Medical Center. “We’ve been practicing and getting annual education with teach-back for several years.” But when Iowa Health received a Picker grant, the organization decided to study just how much and how well they were using teach-back. They were unpleasantly surprised. “We thought we were using it, but we weren’t,” Cundy says.

As part of the grant, they developed a tool kit and began studying whether coaching could help beef up the method’s use. “We wanted to hardwire this into our heads,” Cundy says. “We thought that if we could have someone there who could point out exactly when you weren’t doing it, they would have a light bulb go off and learn from the experience. We would help people make this an always event.”

So Iowa Health started using observers to evaluate what providers were telling patients, grade them on a competency scale related to the use of teach-back, and then coach those who needed it on improvement strategies.

Not everyone is being graded on the competency scale — Cundy’s unit isn’t using it — but the observations, which began on a single unit, are expanding throughout the organization’s four hospitals and other facilities.

There are some 300 observers and coaches. Cundy says that managers nominate coaches — usually those who have a passion for patient education and who have used the teach-back method naturally, as a matter of course even before the program was introduced at Iowa Health. “It’s the way they teach by nature,” Cundy says.

How often people will be observed isn’t settled, she says. “It will be more than once a year, though.”

Most providers know it’s the right thing to do, and many are sure they are doing it — until an observer points out that in that last patient encounter, they asked yes and no questions, or forgot to have the patient repeat back what their medication regimen would be on discharge, Shriver says.

Patients still get booklets, pamphlets, reading material, but Shriver explains that the education they get directly from providers is probably more important, and asking them to repeat back their understanding of what you just told them is a great way to get what they need to know to stick in their mind.

The coaching and grading are new, so Shriver says she isn’t sure how well they will work at improving both the quantity and quality of teach-back to patients, but she’s pretty sure they will have a positive impact. And teasing out whether that might help reduce readmissions or other less than optimal outcomes may be impossible. “Everyone is working on a lot of things related to reducing readmissions. I think in home care we can see what patients are calling about, but in the inpatient setting, it might be harder.”

Shriver says providing your staff with the teach-back tools and training (available online at isn’t enough. “Everyone knows it makes sense, but you have to go out and practice. You have to role play. And people don’t like doing that even if it does help develop their skills.”

Having the observations — something that Iowa Health has been doing for other projects and thus isn’t a scary or threatening occurrence for staff — is a way to emphasize that everyone can use some practice.

Shriver says what helped get people to agree to role play is giving them the power over what scenario they use. “We ask them to choose an example from their own experience,” Shriver says. “If they can’t come up with one, we have some already created, but it helps if they can directly relate to the examples.” They are asked to take turns being the provider and patient.

Another element to getting teach-back to work at its best is to get people to understand that patient education isn’t something that only happens at discharge, but can happen at any time in any setting. And possibly with any hospital employee.

Right now, it’s something that only those who have direct patient education as part of their regular practice are trained in, says Rita Corbin, BSN, MS, RN-BC, clinical education specialist at Iowa Health. But in the future, she could see housekeeping and others being trained, too. “Imagine someone saying, ‘Can you show me how you would use the call button?’” That’s teach-back.

Competency evaluations will continue for the next six months. Corbin hopes that improving how providers give patient education will translate into better scores in patient satisfaction and communication with medical staff categories of the HCAHPS surveys.

Cundy thinks it might help with the communication about medication scores, too. “They are good now, but we can always do better,” says Cundy. “To me, it’s all about the patient. I want to know when I send the patient home they will take their meds correctly and safely, they will follow the diet that will keep them healthy and safe and out of the hospital. It is about doing the right thing for the patient. You see it every day — a patient goes home thinking she understands, but they forget, or they lose that piece of paper, or they don’t understand the lingo. When they repeat it back to you, it sticks with them.”

For more information on this topic, contact:

• Deb Shriver RN, MSN, CENP, Chief Nurse Executive, Trinity Regional Medical Center Fort Dodge, IA. Telephone: (515) 574-6609.

• Rita Corbin, BSN, MS, RN-BC, Clinical Education Specialist, Iowa Health, Des Moines, IA. Telephone: (515) 241-5288.

• Denise Cundy, MS, RN, NE-BC, Nurse Manager, Iowa Methodist Medical Center, Des Moines, IA. Telephone: (515) 241-6050.