Chapter 17: Creating Health Literate Hospitals: From Admission to Discharge

A major problem with hospitals today is that they are designed for doctors and the medical staff - not for patients. While these five-star establishments can inspire awe and confidence, they also make patients feel insignificant and terrified.

The health literacy environment of a hospital speaks volumes about the facilitys commitment to its patients. You can see evidence of this in the physical attributes of the hospital, such as signboards and postings in vernacular, pictorial language to help users navigate their way; in print materials such as medical history forms, information booklets, and consent forms that are patient-friendly; and in the ability of the staff to talk to patients in plain language and with understanding, empathy and courtesy. Forward-looking hospitals that put patients first will ensure that promoting health literacy is one of their priorities and will use technology to do so effectively and efficiently.

Signage

A picture is worth a thousand words. A simple way to help people with limited language and literacy skills is to provide signage and symbols that assist patients in finding what they need. Multilingual signs are best if you only have a few languages in your practice, but if you encounter people from many different cultures, symbols may be a better way to communicate universally with more people.

HablamosJuntos ("We Speak Together") is a project from the Robert Wood Johnson Foundation that has developed 28 easy-to-understand health care symbols for use in healthcare settings.

For example:

Please visit their website @http://www.hablamosjuntos.org/ to download a complete set of symbols at no cost, and for ideas on how to use them in your practice.

Brach et al (2011) developed a series of 10 Attributes of Health Literate Health Care Organisations to help them support health literacy. While these are primarily designed for large hospitals, they can be applied to clinics as well:

1. Make health literacy a priority; it should be an integral part of your mission. Include health literacy in all planning and evaluation activities. Conduct regular evaluations of your organisations physical environment and internal support systems for health literacy. Ask your low literacy patients for help assessing the impact of your programs and policies.
2. Train staff members in health literacy. Make best practices such as teach-back and plain language known to all staff members and develop a standard training program for current staff at all levels. Include your low-literacy patients in the planning, implementation, and evaluation of health services.
3. Respect them - they are the ones who are likely to provide the most ingenious solutions, because they have to live with these problems daily.
4. Implement Universal Precautions as a method for reaching people with a range of literacy skills and avoiding stigmatisation.
5. Implement specific health literacy strategies to ensure understanding before, during, and after interpersonal communication.
6. Foster a culture of clear communication in which questions are welcome and comprehension is regularly verified. Where possible, provide interpreters for patients whose native language is not English. Limit instructions and messages to two or three main ideas at a time.
7. Provide assistance with navigating the organisation, internally and externally. Provide universal visual signage for facilitating movement. While your staff may know your building like the back of their hand, its very easy for visitors to go around in circles- especially when they are sick. When possible, group related services and clinics in similar locations so patients dont get lost. Provide patient navigators to personally guide people through your building(s).
8. Provide multiple types of health information including print, audio, video, online and interactive materials that are easy to access and comprehend. Involve your patients and their caregivers in the development of easy-to-understand material in multiple media formats, such as audio-visual kiosks for patient education. Test your materials for readability and cultural suitability. Do not worry about making your material "too simple", because research has shown that even those with no literacy problems prefer clear, simple materials. Make sure your hospital website becomes a trusted source of Information Therapy for your patients and caregivers.
9. Highlight high-risk situations in which health literacy interventions may be critical to patient outcomes. It is important to identify those situations that carry a high risk of miscommunication and poor outcomes. Examples include: providing informed consent prior to surgery, end-of-life decisions, and discharge from hospital. Provide extra help such as interpreters, peer support, and video or audio materials to ensure these high-risk times are dealt with appropriately and sensitively
10. Provide assistance with understanding health insurance plans, bills and out-ofpocket xpenses.

These are exactly the kind of doctors who give hospital CEOs a nightmare, because they are not very compassionate and can be quite rude and brusque while dealing with patients. The CEOs fear is that in case there is a complication with one of the patients, the patient will want to sue because he is angry at the way the star doctor treated him. Simply because the doctor is so busy and sees such a large number of patients, its pretty much inevitable that there will eventually be a complication. If this unhappy patient is not handled properly, he will end up suing both the doctor and the hospital. This can cause enormous damage to the hospitals hard-earned reputation, which may have taken years to build. Any hospital CEO will vouch for the fact that this happens with surprising frequency - and they have to work hard to hush hours up.

Hospitals often have very poor mechanisms for ensuring informed consent and many "big-shot" doctors may not even bother to take informed consent personally from the patient. If informed consent is not provided properly, this is potentially a medico-legal malpractice suit waiting to be slapped on the hospital, if and when something goes wrong. As a basic rule of risk management, its far better to prevent problems, and expecting doctors to improve their behaviour is unrealistic. Rather than indulge in wishful thinking, hospitals can use their website to ensure that patients are armed with the right information. The beauty is that because this information is being provided on the website, the doctor does not need to provide this information himself, so it doesnt end up eating into his precious time. In fact, online Information Therapy improves the doctors efficiency, because he is reassured that his patient is well-informed and can move on to providing actual medical care, rather than spend time educating the patient face to face.