Guide to Implementing the Health Literacy Universal Precautions Toolkit

Patient Self-Management & Empowerment

Tool 14: Encourage Questions

The goal of this tool is to provide your practice with strategies for eliciting questions from patients. These approaches, when used over time, can teach patients to become more involved in their care.

Tips for Launching a Campaign to Encourage Questions

  • While encouraging questions is something individual staff members can do, an organized, practice-wide campaign is more likely to succeed.
  • Use educational sessions and training opportunities (e.g., all-staff training) to raise awareness about health literacy and its importance, and to introduce strategies for encouraging questions from your patients (Tool 3).
  • Different members of your staff can play a role in eliciting questions from patients. For example:
    • Schedulers and front desk staff members can remind patients to write down the questions they want to ask their doctor before the visit. They can also suggest bringing along a family member or friend to help patients remember their questions.
    • Include a place for patients to write down their questions as part of an existing form patients complete when they come to your practice. Go to the Adult Return Visit Update Form as an example.
    • Rooming nurses can ask patients, "What questions do you want to discuss with your [doctor/nurse practitioner/physicians' assistant] at this visit?" and document this information.
    • Clinicians' use of the Teach-Back Method can prompt questions from patients if they don't understanding what they have been told.
  • Use campaign materials to bolster your efforts. Order or create print materials that will help you implement your chosen strategies. These may include:
    • Ask Me 3 patient brochures, notepads, or posters. If materials are not available from the Ask Me 3 Web site, try creating your own.
    • Place these materials in visible locations in your practice to encourage patients to think of their questions while waiting to see their provider.
    • Wear "Ask me—I can help" buttons. These buttons come with the AMA health literacy kit, or can be made to order.
    • Refer patients to "Quick Tips—When Talking to Your Doctor" or "Questions to Ask During Your Appointment" from AHRQ's Questions Are the Answer campaign.

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Tool 15: Make Action Plans

The goal of this tool is to help patients make changes to improve their health by creating action plans.

Tips for Implementing this Tool

  • Try this tool in conjunction with other relevant tools.
  • Evidence that action plans make a difference can motivate a practice to start using them. This abstract describes a randomized controlled trial that showed action planning can significantly improve diabetics' HbA1c levels and maintain improvements for 1 year.
  • Show the American College of Physicians video at lunch time and discuss. Discussion questions could include:
    • Do we have any patients who have difficulty with self-management that could benefit from action planning?
    • Are there particular conditions that we might want to target or would action planning be useful to all our patients?
    • Do we want a couple of clinicians to try out action planning and report back to the rest of us?
    • What might make it difficult for our practice to help patients make action plans? How could we address those challenges?
  • Practice conducting action planning discussions. This can be done in groups of three with one person playing the clinician, another playing the patient, and a third as an observer to give feedback. After everyone has a turn at each role, have them repeat the exercise, this time instructing the "patient" to be unenthusiastic or indecisive. Talk as a group about what's hard about these discussion and share strategies on how to engage patients without telling them what to do.
  • Place action planning forms in patients' charts or in the exam room before the appointment. This will serve as a reminder to complete the plan during the visit. If your practice is paperless, explore adding action planning functionality to your EHR.
  • Plan out the workflow involved in using action plans. For example, who will copy or print the plan for the patient before he or she leaves?
  • Explore which staff members can develop, follow up, and update action plans. For example, the primary care clinician may be the one to first talk about goals and the action planning process, but nurses or educators may be the ones to work with patients to develop, follow up, and update plans.

Tips for Working with Patients

  • It can be tempting to make suggestions, but action plans need to come from the patients. Try having a menu of options (e.g., lists of exercises, foods to cut down on) that can give patients ideas for specific steps they can take. has lots of suggestions for making healthy changes.
  • Ask patients when they want to start. Having a concrete date sets patients in motion.
  • Ask patients whose help they can enlist in completing their action plan. Support at home is an important determinant of success.

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Tool 16: Help Patients Remember How and When to Take Their Medicine

The goal of this tool is to outline some approaches your practice can use to help patients manage their medicines, reduce medicine errors, and improve medicine adherence.

Tips for Implementing this Tool

  • Building new EHR capacities can greatly ease the implementation of Tool 16. If possible, make changes to your EHR that allow you to:
    • Prompt your clinicians to ask one or more of the recommended questions:

      "Do you have a way to remember to take your medicines?"

      "Everyone forgets to take their medicine from time to time.When was the last time you forgot to take any of your medicine?"

    • Document your patient's responses to these questions and the methods used to educate and help them manage their medicines.
    • Automatically generate a medicine list that is easily read and understood by your patients. Unfortunately, EHR-generated lists are often not easy to understand.
    • If possible, try one of the following.
      • Work with your IT department to build an EHR application that can create personalized medicine charts for your patients.
      • Engage an EHR expert to extract needed information out of your system in the format you want. A practice facilitator may be able to help you locate an EHR expert.
      • Show your EHR vendor an example of what you'd like medicine lists to look like and discuss the options.Your request is more likely to receive attention if many practices ask for the same modification.
  • Given the time and effort that it would require to use personalized medicine management strategies with all your patients, practices might consider which of their patients would most benefit from this service.
    • Your practice may target patients who take multiple medicines or medicines that are dangerous if taken incorrectly, have cognitive impairment, report significant medicine side effects, or have known financial difficulties or health literacy limitations.
    • If your practice is already conducting medicine reviews, you can use this process to systematically identify the most appropriate patients to target for personalized medicine management strategies.
  • If you are considering purchasing a Web-based reminder system for your patients, involve patients in the decision to make sure the system will meet their needs.

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Tool 17: Get Patient Feedback

The goal of this tool is to provide your practice with guidance on how to obtain and use patient feedback about health literacy issues. This tool introduces you to four strategies: shadowing patients, doing a patient walk through, getting patient feedback on written material, and surveying patients.

Tips for Conducting Patient Shadowing and Walk Through

  • Ideally, you will obtain feedback using more than one method. When deciding where to start, think about starting with patient shadowing or patient walk through. They can be accomplished quickly and cheaply, and are often an eye-opening experience.
  • Consider establishing a Patient Advisory Council. This council can serve as an ongoing mechanism to obtaining feedback from patients. This Institute of Patient- and Family-Centered Care provides further guidance about Creating Patient and Family Advisory Councils (PDF File, 321.5 KB).

Tips for Surveying Patients

  • Be clear about your purpose in surveying patients.
    • If your goal is to get a quick read from a large group of patients, consider using the brief Patient Feedback Form. This survey can be used repeatedly with a convenience sample of patients.
    • If you are trying to establish an evidence base to defend investments, or justify further investment in health literacy improvement, you may want to choose a validated survey instrument, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician & Group Survey—Item Set for Addressing Health Literacy. You will also need to use more rigorous sampling and administration methods.
  • If your practice plans to administer the survey without the assistance of a vendor, there may be other individuals who could help you with these activities.
    • Practices affiliated with large health systems may consider partnering with departments that bring additional resources and knowledge to your team (e.g., research, patient satisfaction, quality improvement).
      • Be realistic in your timeline and goals. Even if you have engagement and help from invited departments, you may still need to get formal permissions to administer the survey.
    • Residency practices may also look to residents and residency faculty working on QI projects for expertise and help with fielding and analyzing surveys.
  • Getting a high response rate (e.g., completed surveys from a large percentage of patients sampled) is notoriously difficult. Have the health literacy team come up with ideas to encourage patients to complete surveys. For example:
    • Hand out a pedometer for completed surveys.
    • Have check-out staff members remind patients to complete surveys.
    • Hang posters.
    • Reinforce how important it is to get feedback from patients.

Tips for Using Survey Feedback

  • Don't set your practice up for failure by obtaining feedback before the changes you are making have become established. Obtaining feedback too early may discourage staff members from continuing with health literacy work.
  • Staff members may say, "That's not me they're talking about," when patient reports are negative. Try to emphasize that everyone has room for improvement.
    • If some staff members are particularly resistant to accepting global feedback, consider obtaining staff-specific feedback (e.g., shadow a patient who interacts with that staff member).
  • When you ask patients to give feedback, let them know how their feedback was used. Let them know about changes that have been made as a result of their feedback.
    • Post announcements regarding how patients have helped improve the practice on bulletin boards.
  • Don't forget to keep all practice members continually informed about your progress. Use all-staff meetings to report the feedback that you have received (both good and bad).

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Page last reviewed January 2015
Page originally created January 2015
Internet Citation: Patient Self-Management & Empowerment. Content last reviewed January 2015. Agency for Healthcare Research and Quality, Rockville, MD.