Health Literacy Universal Precautions Toolkit, 2nd Edition

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Overview

Frequently, practices are unaware of the level of difficulty patients encounter in reading or completing forms, understanding health information, and navigating the health care system. Patients are in the best position to judge if a medical office poses health literacy challenges. Getting patient feedback can highlight features of your practice that may cause difficulty for patients and help you identify areas for improvement.

Action

Choose from among the following ways to get patient feedback. Using multiple methods of gathering patient feedback will improve the caliber of the information you receive.

Shadow patients.

• Have a staff member shadow patients. A staff member (like a nurse, nurse educator, or physician's assistant) can accompany a patient during a visit, as a quiet observer. Shadowing can provide valuable insight into how a patient experiences your practice flow and communication. The PowerPoint presentation, Navigating the Health Care System, describes the kinds of information you can obtain by shadowing a patient.
• Decide how many patients you want to shadow and the timeframe within which you would like to complete the shadowing.
• Select patients to shadow who are representative of your practice in terms of age, gender, race/ethnicity/language, and health issues. A mix of new patients and patients who have been coming to your practice for years is ideal.
• Before their appointments, tell selected patients about your goal of improving patients' experiences in the practice and ask if an observer can accompany them during the visit. Be aware that not all patients will want to be observed.
• When shadowing patients:
  • Stay with them from the time they check in until they leave. Consider arranging to meet them outside your practice to see how easy it is to find your practice entrance and check-in desk.
  • At the end of the visit, ask the patient what went well and what was difficult about the visit.
  • Complete Communication Observation Forms (go to Tool 4: Communicate Clearly) after each visit observed. This form focuses on the quality of communication between staff and the patient. Supplemental items can be added to address other target areas in which your practice is interested.

Conduct a walk through.

• Have a person unfamiliar with the practice walk through it with a staff member and give feedback on the signage and the physical environment.
  • Be sure that anyone who conducts a walk through will not observe any private or confidential interactions.
  • Consider recruiting a student from a local adult education program to conduct a walk through.
  • The Health Literacy Environment Activity Packet (PDF, 142 KB) provides detailed guidance on the sorts of questions you can ask observers about their experience.

Observe patients using your patient portal.

• If you have a patient portal (i.e., personal health record), ask several patients if you may observe while they use the portal. Try to include patients who are not very experienced using computers.
• After you let them explore the portal, ask them to complete a specific task (e.g., find information on a particular topic, look up their recent lab results, request a prescription refill) and ask them to describe what they are doing. Observing how patients use the portal will help you know where changes in appearance, wording, organization, or navigation of the portal may be needed.
• The Patient Portal Feedback Form contains a list of questions you can ask to gather feedback from a patient about his or her experience using the portal.

Ask patients for feedback on forms or other materials.

• While a patient or family caregiver waits for a visit, or at the end of a visit, ask him or her for feedback on how understandable your written materials are. Remember to evaluate materials you did not develop as well as materials you created.
• Go to Tool 11: Assess, Select, and Create Easy-to-Understand Materials for more information on selecting and developing materials that will be easy for patients to read and understand and Tool 9: Address Language Differences for information about materials in multiple languages.

Have a suggestion box.

• Let patients and caregivers know you want to hear from them about any difficulties they have understanding information they have been given or getting the help they need. Use this poster to encourage patients to suggest ways your practice can improve communication.

Survey your patients.

• You can gain valuable insight from patients by conducting a survey. There are five main decisions to make when surveying patients.
• Choose a survey tool. There are a number of surveys you can choose. For example:
  • The Brief Patient Feedback Form from Tool 4: Communicate Clearly captures patient feedback on patient-provider communication. The form can be easily modified to include questions that address other areas of particular interest to your practice. The surveys described below provide a variety of questions that you may want to include.
  • The Health Literacy Patient Survey assesses a patient's experience communicating with staff, the quality of written materials, and referrals to community resources.

The CAHPS® Item Set for Addressing Health Literacy has questions on the quality of written and verbal communication with patients. It was designed to be used with the CAHPS Clinician & Group Survey. About the CAHPS Item Set for Addressing Health Literacy (PDF, 286.8) gives you an overview of the questions and how to use the survey results for quality improvement.

• Choose a patient population to survey. How you choose the patients to survey can impact the feedback you receive.
  • You can use a convenience sample of patients (e.g., all of the patients who came in this week). Be aware that a convenience sample won't be perfectly representative of your entire patient population. For example, a sample of patients who visited the office during a given week will include a higher proportion of patients who have frequent office visits (e.g., those with chronic conditions).
  • You can use a random sample of patients (e.g., choose every third person on your patient roster). A random sample of patients is generally better because it is representative of your patient population. To measure improvement over time, however, you have to limit the sample to patients who have had interactions with the practice since changes were made.
• Choose how many patients to survey. There is no set number of completed surveys that will automatically provide you with a reliable source of information. Generally, though, obtaining 50 completed surveys will give you a good idea of how your practice is doing. The larger the number of patients who respond to your survey, however, the more confident you can be in your results.
• Choose how to administer the survey.
  • Administering surveys by having someone ask the questions on the phone or in person may make participating easier for patients with limited literacy skills. Because patients may be concerned about providing negative feedback to staff they know, try to identify a volunteer from outside the practice who can collect survey data.
  • A Web-based or tablet-based version of your survey can help you collect and analyze survey data, and may provide audio options to address literacy barriers. Use Web search terms like "electronic survey tools" to find available options.
  • Use a cover letter to introduce and explain the purpose of the survey to your patients.
  • If you are surveying patients coming in for an office visit, we recommend that check-in staff ask each patient if he or she would be interested in providing your practice with feedback to improve care. Make it clear that it's their choice, and their care won't change if they say no. If they say yes, ask patients to complete the survey at the end of their visit, before they leave.
  • Regardless of how you collect data, patients are likely to be more honest if they know that their responses will be kept confidential. Devise a system for ensuring that patient's individual responses are not linked to them in an identifiable way and only aggregate results are shared with their clinicians and other staff. Let patients know that their responses will remain private.
• Choose how to analyze survey results. There are vendors who can help with the collection and analysis of CAHPS data. Hiring a Survey Vendor provides information on locating a vendor. Staff can create a spreadsheet and enter survey responses into it. Then, you can total the number of low and high ratings to help you understand your survey findings.

Act on your results.

• Bring aggregated results back to the Health Literacy Team when you have finished obtaining patient feedback.

  Be sure that the data do not identify specific patients and their responses.
  
  Identify areas for improvement.
  
  Use Tool 2: Create a Health Literacy Improvement Plan to identify tools that can address targeted areas for improvement. Plan, implement, and test changes to see if they addressed the concerns identified.

• Collect patient feedback as a routine part of your quality improvement activities. Obtaining patient feedback is not a one-time activity. It should be done on a routine basis. Consider obtaining feedback from a sample of patients every quarter.

Track Your Progress

The Health Literacy Team should examine efforts to obtain patient feedback. Ask yourselves:

• Have you carried out plans to obtain patient feedback? For example, were you able to shadow the number of patients you wanted to, and did you complete the process in your allotted time?
• Have you used multiple methods to obtain patient feedback?
• Have you obtained feedback from a sample of patients who are of varying ages, racial/ethnic/language groups, health conditions, and both genders?
• Have you identified improvement goals based on feedback?
• Have you implemented improvement plans?
• Have you obtained additional patient feedback to assess whether you have achieved your improvement goals and identified new improvement areas?

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