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The Joint Commission calls for comprehensive action on poor health literacy

Low health literacy is a much bigger problem than most healthcare professionals realize, affecting nearly half of all Americans, according to The Joint Commission.

In fact, calling the problem a silent epidemic, the Oakwood, IL–based accrediting organization has unveiled a public policy white paper outlining a long list of recommendations designed to guide individual providers and healthcare organizations toward formulating solutions.

Although poor health-literacy affects all facets of healthcare, it is particularly damaging to chronically ill patients who may have difficulty learning and understanding important self-management skills.

The problem is compounded by the fact that people with low literacy often do their best to hide reading deficiencies, because they lack confidence or feel ashamed.

There is no doubt that poor health literacy costs the country dearly in terms of quality of life as well as dollars spent on complications or mistakes that occur as a result of communication gaps.

Consequently, policy makers maintain that it is in everyone’s best interest to participate in a comprehensive solution.

Problem is widespread

In unveiling its white paper What Did the Doctor Say?: Improving Health Literacy to Protect Patient Safety, The Joint Commission emphasizes that in its own active database, which documents more than 3,000 preventable deaths and serious healthcare injuries and their underlying causes, analysts have identified communications failures as a contributing factor in almost 70% of the cases.

“While not all of these relate to health literacy or language and cultural barriers, many likely do,” says Dennis O’Leary, MD, president of The Joint Commission. “We need to reflect on the fact that if a patient does not understand his or her illness, what medicines need to be taken, how to take them, and why these medicines are important, we have lost the treatment battle at the beginning, and we may have unwittingly placed the patient in harm’s way.”

Communication problems are not only affected by poor health literacy, but also by language barriers and cultural differences, adds O’Leary. And individual providers often don’t realize that there is a problem. “When I went to medical school, no one warned me that up to half of my patients might not be able to understand me,” says O’Leary. “And today, many physicians believe they have been clearly understood by the patient when clearly they have not.”

The white paper (available at www.jointcommission.org) outlines 35 steps that providers and healthcare organizations can take toward remedying the problem. These include

  • training and education for clinicians and allied personnel on the scope of the problem, as well as on patient-centered communication strategies
  • development of patient-friendly navigational aides at healthcare facilities
  • healthcare organization assessment of literacy levels and the language needs of the communities they serve
  • integration of patient communication priorities into pay-for-performance programs
  • provision of medical liability discounts for physicians who apply patient-centered communication strategies
  • expanded adaptation and use of adult learning centers to meet patient health literacy needs
  • redesign of informed consent forms and the informed consent process
  • enhanced training and use of interpreters for patients

    Providers should be aware of other clues

    Experts agree that taking on the issue of low health literacy is a major undertaking that requires the participation of all key players. However, there is a lot that individual providers can do to address the issue in their own practices. “The bottom line is awareness that the patient who smiles at you and nods their head doesn’t necessarily understand what you said,” says J. James Rohack, MD, chair of the American Medical Association’s Board of Trustees, and a practicing cardiologist in Temple, TX.

    Rohack advises providers to use the “teach-back” method to confirm that patients fully understand what you have attempted to communicate. This involves simply asking patients to explain back to you the instructions or education that you have just delivered to them.

    It takes some time, but Rohack emphasizes that it is a simple way to confirm that patients comprehend important medical information.

    Rohack also advises providers to be aware of other clues that their patients may have low literacy skills. For example, he uses the medical history form to pick up on communications deficits. “If patients don’t fill out the form, that is a clue; or if they are not able to write down what medicines they are on, that’s a clue,” says Rohack.

    When there is a communication deficit, Rohack emphasizes that providers and front office staff need to take special care to make sure patients do not feel that they’re responsible for the problem.

    “The patient has to feel that we in the doctor community . . . are not blaming or shaming him [or her], and that we understand that there is a communication need that we need to meet in a different way other than the written word,” says Rohack. “If we can’t communicate, we can’t provide good patient care, we can’t provide good quality care, and we certainly can’t provide safe patient care.”

    Even with patients who are highly literate, sometimes physicians give them more information than they can absorb in one setting, notes O’Leary.

    A better strategy, he says, is to prioritize the information into two or three main points during each encounter.

    In fact, such planning can be essential when trying to impart key self-management skills to the chronically ill. “Patients who are good at self-management are much less likely to end up being hospitalized, so it is a way of reducing healthcare system exposure and keeping people healthy,” he adds.

    Reimbursement policies need attention

    Making sure that patients clearly understand instructions requires more time, but O’Leary says that it is “time that is incredibly well-spent.”

    Consequently, he points out that payers need to devise ways to reimburse providers for this time.

    “It really is a challenge where time constraints are increasingly a problem in physician practices, and payment systems really don’t properly recognize the needed effort on the part of physicians,” he says.

    In addition, O’Leary maintains that medical liability insurers have a strong stake in the issue as well.

    “They know as well as we do that communication issues are a huge patient safety problem,” says O’Leary. “That is a big exposure for practitioners and provider organizations, so anything [medical liability insurers] can do to encourage more effective communications between doctor and patient is a business proposition for them.”

    For example, O’Leary notes that medical liability insurers could provide discounts to physicians who can demonstrate that they meet expectations in this area.

    In its accreditation work, The Joint Commission plans to refine its own standards with regards to National Patient Safety Goals so that surveyors focus more attention on communications strategies that organizations employ to circumvent poor patient-literacy skills and other communication barriers.