Running patient education across an organisation
An organisation that holds a large set of standing patient materials has to keep the set consistent, findable, current and in use, argue for the budget the set needs, get plain words past its own objections, and reach readers in their own communities.
Inconsistent and unfindable materials
Intermountain Healthcare, a nonprofit system of 21 hospitals, 162 clinics and more than 28,000 employees and the largest healthcare provider in the Intermountain West, found it difficult to ensure the quality and consistency of patient education materials across the system. A survey of its printed information in 2005 confirmed two suspicions: the materials being distributed were inconsistent in both quality and content, and staff either did not know that system-approved materials existed or did not know how to access and order them. To improve the quality, consistency and availability of its materials and to support clinical best practice, the system developed a process for creating and distributing patient education fact sheets across the organisation.
Templates for each type of content
To make content consistent, the system wrote its fact sheets from templates for three types of content:
- Procedures and treatments: basic information on how the procedure is performed, what to expect, and basic discharge and home-care instructions.
- Diseases and conditions: basic information including causes and symptoms, diagnosis, treatment and prevention.
- How-tos: simple step-by-step instructions for a self-care procedure, such as using crutches or caring for an intravenous line.
Clinical approval, visual consistency and distribution
To make clinical content consistent and accurate, every fact sheet was reviewed and approved by system-wide clinical teams. To make design consistent, colour shells pre-printed on high-quality paper were stocked at copy centres throughout the coverage area.
To support system-wide distribution, all fact sheets were posted on the employee website, and through an online ordering system any facility could order them, have them printed inexpensively on the pre-printed shells and receive them the next day. To increase awareness and promote use, their availability was announced through email announcements, articles in the employee newsletter and a month-long promotional banner on the employee website's homepage.
What the process achieved
The process improved the quality and consistency of the materials distributed across the system and the efficiency and productivity of creating them, made materials easy to update when information or practice changes, improved awareness and ease of ordering, increased use of the system-approved materials, and led to better patient care.
Literacy review, tailored leaflets and supplied materials
At one hospital the communications department reviews patient leaflets to make sure they meet the standards of the National Adult Literacy Agency, which improves patient comprehension. The clinical pharmacy keeps a database of commonly used, tailored leaflets developed in line with those standards, which give essential, patient-relevant information to support understanding and informed decision-making. The hospital has no formal process for involving patients in creating personalised education materials.
One of those tailored leaflets covers medicines containing animal-derived ingredients, for vegetarians, vegans and people who wish to avoid animal products for religious, cultural or ethical reasons. The pharmacy team found no information about the source of the medicine, so they included it in the leaflet, which lets those patients make informed choices aligned with their values.
Pharmaceutical companies can supply educational booklets to the hospital free of charge to improve patients' comprehension, and the National Medication Safety Network reviews them to make sure they include all important information, including risks and benefits. The hospital's clinical pharmacist also shares YouTube videos produced by the hospital and by pharmaceutical companies, on the view that everything that potentially helps patients' understanding is welcome, and in that pharmacist's experience such tools can promote health literacy and empower patients.
The case for investment
At the Cleveland Clinic, a review of a sample of print-shop invoices estimated what the institution spent on patient education materials and found the amount was less than it spent on business cards. That finding was used to argue that both the quality and the quantity of the materials should be improved.
Getting plain words accepted inside the institution
Changing health education materials from ones that demand a high level of reading skill to ones that take account of their audience's literacy was a struggle at one children's hospital. The nurse who led that effort sees producing suitable materials as two steps: first identify and engage the target audience, then facilitate a cultural shift using marketing strategies.
The hospital's administrators first reacted negatively to the words "pee" and "poop" in patient materials and wanted more delicate terms, such as "urination", in brochures meant for the broader patient population. But medical writers are not the ones whose health literacy is under discussion, and for health education materials to be effective they must be written to reach an audience with a fifth- or sixth-grade level of reading literacy.
The county hospital system for Dallas County serves a largely underprivileged population, many without health insurance, who as a result often wait too long to care for their health and end up in the emergency department. Its nurses undertook an initiative to heighten awareness of low health literacy, beginning with the Reading Level Determination Study of 1984, and since then the problems of low literacy and the principles of teaching this population have received increased attention. In 1998 a set of training materials was created for health care personnel working with low-literacy patients. New nurses and other clinical staff are made aware of health literacy from the start and are encouraged to use words patients understand, asking a patient to "pee in the cup" rather than to "void in the cup".
Reaching readers through their own community
In the Promotores de Salud programme, lay people are trained in a state-certified programme to communicate health practices within their own communities, and these lay health workers are called promotores. One practitioner holds that these lay health workers have helped overcome a social injustice built into the health care system. That injustice is a serious problem in Central Tarrant County, Texas, which has one of the fastest-growing Hispanic populations in the United States. At least 32% of that population is uninsured, and many live in areas the health care system underserves. The promotores fill this gap: they meet friends and neighbours in the grocery store or at school events and can raise health issues in everyday conversation.
In the DREAM project the promotores assessed risk factors for type 2 diabetes in the Hispanic community around Fort Worth, Texas, and encouraged community members to increase their physical activity and improve the quality of their diets. Promotores also do surveys and screening, explain self-management behaviour, stress the importance of keeping appointments with health care professionals and track adherence to medication. Data from the DREAM project indicated a significant decrease in body mass index and in the prevalence of smoking among the families the promotores visited.
The keys to success in promoting health literacy are to forsake eloquence for effectiveness and to rely on cultural connections among the intended audience.