Guide to Implementing the Health Literacy Universal Precautions Toolkit

Path to Improvement

Tool 1: Form a Team

The goal of this tool is to assist practices in assembling a health literacy team that includes membership and participation from all areas of your practice and is led by a committed champion with authority to direct practice change.

Tips for Assembling the Team

Avoid These Common Pitfalls

  • The team leader comes from outside your practice and is unfamiliar with on-the-ground operations.
  • The team leader does not have enough time to commit to the process of implementation and assessment of health literacy changes.
  • Ad-hoc members are not informed or engaged in the decisions and work of the team.
  • Reluctant members are assigned to the team without ensuring full buy-in for their participation.
  • The health literacy team stops meeting after kicking off some initial activities and forgets to regularly measure the impact of their work.
  • Your team leader should have the passion and time necessary to make health literacy QI a priority in every practice area. He or she should know how your practice functions, how its members work together, and have authority to make and sustain changes. Potential team leaders could be senior clinicians, practice managers, or QI experts.
  • Limit team size to no more than 8 team members to help manage logistics.
Potential members of the health literacy team:
Front office staff: Receptionists, schedulers, patient navigators.
Administrative staff: Practice managers and administrators; billing, referral, and medical records specialists; phone triage operators; practice facilitators.
Clinicians and staff: Doctors, residents, nurse practitioners, physician assistants, medical assistants, social workers, psychologists, care managers, patient educators, and laboratory staff.
Don't forget to include patients! Patients and caregivers have key insight into the challenges they face when they interact with your practice and ideas for how your practice could better meet their needs.
  • In selecting members for your team, consider which individuals from the front and back of your practice can best help to…
    • Create buy-in with key practice members (opinion leaders and decisionmakers).
    • Formulate an effective and realistic implementation plan (planners/strategists).
    • Implement desired changes in a timely and efficient manner and sustain them (doers/organizers).
    • Evaluate and refine your changes (patients and data analysts).
  • Practices affiliated with large health systems may also want to include members from departments that bring additional resources and knowledge to the team. These may include marketing and communications, patient education, interpreter services, and health information technology, among others.
  • Practices that are residency training programs should include residents and residency faculty on the team. Connecting health literacy work with residency training requirements to conduct QI work is one way to make residents' participation more meaningful.
  • Sometimes existing practice teams (e.g., QI team) also assume the role of the health literacy team. Make sure its members are committed to health literacy work and have full buy-in for participation. Instead of "assigning" staff to the team, "invite" participation from all potential team members.

Tips for Running the Team

  • Conduct regular team meetings, at least twice a month at the beginning of your tool implementation and at least monthly thereafter to "check in" on progress, brainstorm solutions to barriers, and plan implementation of additional tools.
  • Revisit the three key implementation plan questions listed in the Tool 2 section at team meetings, and collaboratively plan further changes using your implementation plan. Make sure you update your written plan after every meeting.
  • Often practices are so focused on implementation activities that they forget to track their progress. The health literacy team should make sure you are using measures that can help you understand whether or not your implementation efforts are successful, as well as gather the necessary data to measure implementation activities. Don't forget to use the Track Your Progress section of each tool to help you with these tasks. Feel free to identify other methods for measuring your progress.
  • Set up an accountability structure whereby the team reports regularly (at least monthly) to a designated practice manager, QI committee, or practice leader about their progress.

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Tool 2: Create a Health Literacy Environment Improvement Plan

The goal of this tool is to help your health literacy team choose and make a plan for the implementation of health literacy-related improvements for your practice to work on. The Primary Care Health Literacy Assessment will help your practice identify strengths and opportunities for improvement, and the improvement plan will help your health literacy team implement these changes.

Tips for Administering the Primary Care Health Literacy Assessment

  • Lay the groundwork for the assessment by explaining to practice members that the intention is to understand how different activities are occurring in all aspects of the practice and from all perspectives.
  • Before having the members of the health literacy team complete the assessment, review each item so everyone is on the same page about what is being asked. Try to avoid discussions about how your practice is performing on these items. Once shared understanding is established, everyone should complete the assessment individually, not as a group exercise.
  • Reassure those completing the assessment that it is OK to mark "not sure" when they are not aware of health literacy-related aspects of the practice (e.g., automated phone system) or if they are not familiar with a specific health literacy concept (e.g., teach-back).
  • Underscore the importance of completing the entire assessment. Team members may think they know which areas are relevant to their improvement work and want to skip sections or items they think are not pertinent. Explain that the practice's improvement priorities may shift after they see the assessment results.
  • Ensure that all health literacy members have completed the assessment in advance of the health literacy team meeting where results will be discussed.
  • Your team may decide it wants input from the entire practice staff. While it can be more time consuming to get all staff members to respond to the assessment, it can help to raise awareness and buy-in for health literacy improvement efforts. If you decide to ask all staff members to fill out the assessment:
    • Consider setting up an online survey that automatically tallies survey responses and generates customizable reports, especially if your practice is large.
    • SurveyMonkey® has created a template that allows you to administer the Primary Care Health Literacy Assessment electronically.
    • Emphasize that the assessment survey is confidential to encourage candid responses. If you are using hard copies of the assessment, make a drop box available in a designated area of your practice for staff members to turn in completed surveys.
    • Get senior leadership in the practice to reinforce the importance of completing the assessment.

Tips for Using Assessment Results

  • Assessment results are intended to help you set improvement aims for your practice and choose corresponding tools. Therefore, it is important to have complete results before tools are chosen.
  • Tally and synthesize the results of the assessment, and discuss them with the health literacy team. Consider how the results could help you answer the following questions:
    • What interesting things did you notice in the results?
    • In which areas did you find agreement, and in which areas is there disagreement?
    • Which are areas of strength, and which areas need improvement in your practice?
    • Which areas for improvement are most important for the practice?
  • It's common for individuals to have divergent views of what is happening in the practice. If you see different opinions for a specific item, you may find that some parts of your practice have adopted health literate practices, whereas others have not. Such results could point you to important areas for improvement.
  • In order to build and maintain buy-in for your QI work, the health literacy team should collaboratively make choices about tool implementation, as opposed to having one or two people making this decision for the practice.
  • Sharing assessment results and aims with the whole practice staff can build enthusiasm and buy-in for your work. You may want to share this information during an all-staff meeting or a lunch and learn session.
  • Consider whether opinion leaders and staff members who will be responsible for implementation activities are supportive of the needed changes. If they are not, understand their specific concerns, and work with your team to find ways to address them.

Tips for Developing a Health Literacy Improvement Plan

  • Develop a clear, written implementation plan for each tool your practice chooses to implement in order to ensure:
    • That all Health Literacy Team members have a clear understanding of the activities and expectations during tool implementation.
    • The Health Literacy Team develops a realistic timeline that takes into account future eventualities such as team member absences, busy periods, etc.
  • 1You can use the Model for Improvement's Plan-Do-Study-Act (PDSA) cycles to create and execute your implementation plan. Learn how to conduct PDSA cycles by using the following resources:
  • Your implementation plan should contain specific and detailed information for how your team will go about making and sustaining each change in your practice. Your plan should clearly specify the change you are making, the starting date of implementation, the tasks associated with making the change, team members responsible for each task, and a target completion date.
  • Regularly update your implementation plan as changes and associated tasks are completed and new ones added. Update the plan with information about new iterations of your changes or tasks as a result of what you learn from previous PDSA cycles. Make sure to update your implementation plan after health literacy team meetings.
  • Your implementation plan should address the following questions:

    Text boxes read: 'What are we trying to accomplish?', 'How will we know that a change is an improvement?' and 'What changes can we make that will result in improvement?' Arrows point to and from these boxes to a Plan, Do, Study, Act circle with arrows pointing clockwise around it.

1. What are we trying to accomplish? 

2. Identify your aims and priorities and use them to establish SMART goals (Specific, Measurable, Attainable, Relevant, and Time bound).

3. How will we know that a change is an improvement? 

Establish clear measures specifying when and how you will collect data using each measure. Each tool in the toolkit recommends measures you can use. However, you can also develop measures that are specific to your practice.

4. What changes can we make that will result in improvement? 

Select the tools you want to implement and describe how you will implement them.

  • Use Module 14: Creating Quality Improvement Teams and QI Plans from the AHRQ Practice Facilitation Handbook for further guidance on how to develop goals, create a QI plan, and monitor your plan's progress.

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Tool 3: Raise Awareness

The goal of this tool is to plan and conduct educational activities to help the members of your practice become more aware about health literacy, why it is important, how it affects your patients, and how you can work together to make health-literacy improvements.

Tips for Conducting Educational Sessions

  • Lunch and learn sessions or all-staff trainings can be very effective for introducing your practice to the basic concepts of health literacy and for building early buy-in. They can also serve as an opportunity to introduce the members of your health literacy team, present results from the Primary Care Health Literacy Assessment, and garner support for additional tools your practice may be implementing in the near future. These sessions can be 1-2 hours long, depending on staff availability.
    • Make sure that as many practice staff as possible attend these sessions. This may mean that you have to conduct multiple sessions to reach all practice staff.
    • Remember to involve both non-clinical staff and those who provide patient care. Members of your non-clinical staff can also benefit from health literacy awareness. Seeing how their work can enhance patient experience can be a morale booster.
    • In order to better engage your learners, include a variety of teaching approaches and materials during the session, such as videos, slide presentations, interactive discussion, role playing, and fun games (e.g., teach me what a colonoscopy is without using the words colon, stool, or rectum). Many of these resources are provided in the Toolkit.
    • Conduct informational sessions every 1-2 months in order to provide updates on the status of your tool implementation activities and to maintain buy-in and enthusiasm from your practice.
    • Don't forget to use sign-in sheets to track the number and type of practice staff (clinicians, front desk staff, administrators, etc.) attending these sessions. Each attendee should complete a short evaluation to help you asses the session's effectiveness in raising awareness, and identify areas for improvement.
  • It's easy and time efficient to combine the implementation of Tool 3 with that of other tools. Educational sessions that go beyond introductory information about health literacy can instruct staff on specific strategies you want them to implement, such as Tool 5: Use the Teach-Back Method.
  • Training residents can be challenging, as they may rotate in/out of your practice every few weeks. Use these strategies to raise residents' awareness about health literacy:
    • Conduct 1-hour weekly sessions with cohorts of 6-9 residents and repeat the same training long enough to train all residents.
    • Schedule sessions on days when residents typically work on required QI projects.
    • Encourage residents to "try out" some of the concepts they learned from the training (e.g., use of plain language) with a few of their patients that same day.
    • Emphasize to residents that they are learning communication skills that will be valuable regardless of their chosen specialty.
    • Inform residency faculty of the training plan and ask for their help in reinforcing good resident behaviors.
    • Incorporate communication strategies taught during your training sessions into the resident-evaluation process and related evaluation forms.

Other Strategies for Raising Awareness

  • Use quick reminders in the form of emails or printed "quick guides" to help your practice develop knowledge and skills in a particular area of health literacy. The content of these reminders should be short (3 - 5 sentences) and include actionable steps staff members can take to improve their skills. You can draw from the information provided in the Toolkit
    • Example: You can help ensure that your patients understand what they need to do when they get home by encouraging them to ask questions. Ask all your patients "What questions do you have?" during every visit.
  • Use medical team meetings, huddles, and other opportunities to teach and reinforce health literacy strategies.
  • Take advantage of "teachable moments." For example, if a clinician expresses surprise that a patient didn't take her medicine because it costs too much, you can remind her to ask patients directly if they have trouble affording their medicine and point her to medicine assistance resources (Tool 19).
  • Make information and resources readily available and visible to keep practice staff members engaged in health literacy work. For example, hang posters, such as Key Communication Strategies (Tool 4), and keep a copy of the Everyday Words for Public Health Communication (Tool 11) in the front and back of the practice.

1Langley G.J., Nolan K.M., Nolan T.W., Norman C.L., Provost L.P. (2009). The Improvement Guide : A Practical Approach to Enhancing Organizational Performance. 2nd edition San Francisco, CA: Jossey-Bass Publishers, Inc.


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Page last reviewed January 2015
Page originally created January 2015
Internet Citation: Path to Improvement. Content last reviewed January 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/impguide/impguide-path.html