10 Attributes of an Organization that supports Health Literacy

Frempong_smJanet Ohene-Frempong in 2014 was invited to work with the Oregon Health Authority on their initiative, Developing Equity Leadership through Training and Action: DELTA. According to Janet, Oregon is a leader in coordinated care.

Goals of the Initiative were:

  1. Reduce healthcare costs and improve equity
  2. Improve the effectiveness of communication as one of many ways to reach those goals.

DELTA has a leadership program for 25 members per year from many fields; e.g., health, education , social service, government.

Part of the DELTA program is to institutionalize best practices in organizations.

  • Oregon is including health literacy issues in the development of equity leadership as well as in their attempt to reduce the cost of providing health care to the most vulnerable.
  • Marginal literacy and effective communication issues impact not only health, but education, social services, law enforcement and even  art and entertainment. Supporting effective communication is supporting those who provide information, service and /or care across literacy levels, languages, cultures, etc.
  • Institutionalizing best practices includes expanding the use of IOM’s 10 Attributes of a Health literate organization for use outside the healthcare industry to indirectly improve health. (10 Attributes is 2012 document. It was a seminal document. We need institutional support, and this document codifies it.)

“A Health Literate organization is health-literacy supportive,” says Janet.

Janet drafted a prescriptive checklist for the DELTA program based on the 10 attributes.

  1. Educational, legal/law enforcement, and social service systems affect health and need to be part of the health literacy solution. Literature in these fields supports a connection between health literacy and issues of importance to these sectors.
  2. If health, educational, legal/law enforcement and social service systems can adopt most of the 10 attributes, they may be able to make a substantial contribution to improve population health.
  3. You must identify barriers that stand in the way: Time and money are the most often cited.
  4. There are many resources on the link between health communication and health equity. (See the citations in Janet’s talk handout.)
  5. The communication skills required to support health, as well as health literacy, apply to those in other fields as well. It takes a community to move people towards health. We can extract principles of health communication and extend them to the entire community.

Health Literacy Insights for Public Health Practice: 3 Case Studies in Disaster Management & Relief Efforts


Health literacy research and practice over these last two decades are enabling us to enrich the clinical encounter, transform health care settings and, hopefully, remove barriers to care and services. It is time however, to adopt and adapt these insights for public health practice. This presentation focuses on three case studies [anthrax,  a hurricane, and a tsunami] related to disaster management illustrating the critical value of health literacy inquiry and application of findings.


Rima Rudd, Sc.D

Senior Lecturer on Health Literacy, Education, and Policy, Harvard School of Public Health

We have to think outside the box to help with:

Preparedness, community health and safety and disaster management

Case 1 Anthrax event of 2001:

Anthrax-laced letters sent to people in communications. We needed to communicate the nature of the substance, risk, health implications, treatment, preventive action. There were problems in the clearance system, rumors, misspeaks, and leaks.

A postcard was sent to all households by the Postmaster General for immediate precautionary action. The language used was uncommon and calls to action were vague and abstract. The design was not great either. The case study identified these needs:

  1. Match level of communication with the average person.
  2. Use plain language
  3. Develop a communication plan
  4. Apply formative research and rigorous piloting. – We know about this and we don’t do it.
  5. Need for ‘first responders’ – Call for help from health literacy experts as part of the first responder team.

Case 2 Hurricane Katrina:

National disaster compounded by political neglect.

They needed basic information.

The available materials were not suitable for the general public. (From HHS, CDC, etc.) They paid no attention to health literacy.

Len and Ceci Doak coordinated a volunteer effort with CDC to prepare accessible information with a 6-24 hour turnaround from submission of originals, and pilot test where possible.

The first responders improved the clarity of the information.

Lessons learned:

  • We must demand rigor in our work.
  • Health materials far exceed the reading skills of most members of the public.
  • Assessment tools can help identify needs.

Case 3 Fukushima City Disaster:

This was a multi-level disaster. Many people left the city, including families with children, but most people were still there. The Public Health Nurses were left to deal with the population. The nurses had difficult scientific info they could not adequately translate. The result was loss of trust and worsening of the situation. The nurses needed to get a glossary of terms and improved health communication skills. Skills were improved; systemic barriers were uncovered for the nurses to engage in the work they need to do.

Lessons learned:

  • Communication clarity influences trust.
  • Scientific info must be translated for health professionals, and further translated for the public.
  • People’s professional abilities were developed and they responded positively to health literacy skill developemt.
  • But training professionals without changing systemic inhibitors places undue stress on professionals.
  • You must pay attention to the institutions that shape peoples (e.g. professionals’) abilities to perform.


  • There’s a mismatch in demands of health info and literacy skills.
  • We must develop materials with respect and vigor.
  • We can learn from assessment tools, but need to develop new ones.
  • Literacy is based on interactions.
  • Health literacy involves multilingual skills on multiple levels.
  • Health Lit requires a supportive political/ normative environment.

Mechanisms for Change

  1. Dissemination of info and discussion
  2. Regulations for text production including strategies for times of chaos. Materials must be pilot-tested as part of development process.
  3. Required training for scientists on how to share information, as well as health communicators and educators.

We need training programs to assess health information and prepare health information. Not just written materials.

We need tools for calibrating math demands, assessing risk communication, assessing entry forms and documents for evaluations and research.

We need studies for communicating to the next level of the public: science, risk, reporting medical and scientific findings, displaying findings, reporting test and study results.

WE HL experts need to work together with other organizations such as volunteer orgs, first respondrs, CDC, FEMA, etc.

“The word is as important as any tool.”

Opening Panel: Deeper Dive: Signposts on the Road to Health Literacy’s Future


Rima Rudd, Sc.D (Rima) – Senior Lecturer on Health Literacy, Education, and Policy, Harvard School of Public Health

Cliff Coleman, M.D., MPH (Cliff)- Assistant Professor of Family Medicine, Oregon Health & Science University School of Medicine

Susan Reid, M.A. (Susan) – Director, Health Literacy New Zealand

Marin P. Allen, Ph.D. (Marin) – Deputy Associate Director for Communications and Public Liaison and Director of Public Information , National Institutes of Health

Michael Villaire, MSLM – CEO, Institute for Healthcare Advancement (Moderator)(Michael)

The panel discussed the current level of health literacy penetration in the U.S. healthcare system and identified some objectives and best practices to strive for in the next 10 years. Following is a summary of questions posed by the Moderator (Michael) and answers from the panel, with some key points bolded.

Question: Where do you want to be in 2026?

Rima: Literacy has become an important variable in health research. We need to go much further into looking at the skills of the communicator, difficulty of materials and context, etc. How do we transform the system to reduce disparities?

Cliff: We have done a disservice to patients by ignoring our responsibility in patient understanding. Rather than putting onus on patients and caregivers, we need to turn the spotlight on ourselves.

The State of training for practitioners: There’s a sizable minority of programs training health professionals – less than half. There’s a giant lack of faculty skill in this area. Academic institutions are not as aware as they should be. And the schools teaching health literacy are not teaching it enough. In a 4-year curriculum, they’re teaching about 3 hours on how to communicate with patients. Out of 362 attendees at this conference, there are only 7 physicians. Doctors don’t know what they don’t know: they don’t know what HL is. And they think they are already good communicators. The ones who think they’re the best communicators are rated lowest by patients.

Rima: Doctors who take a year to get an MPH are growing in numbers. There is lots of enthusiasm among young doctors.

Cliff: There are still physicians who think HL does not apply to their populations.

Marin: HL for the individual saves lives, for the physician it saves time; for the system it saves money. We need to equate HL with these facts. We needed to prove the connection. In the future we need to bring the knowledge we already have into the field and think globally, bringing the whole world in. (There are more than 300 languages spoken in homes in U.S.) The work needs to be more comprehensive and more universal.

Michael: HL field needs to work much more closely with the reading field, as Ceci Doak has said for years.

Marin: We need to bring the knowledge of how adult learners learn to the field.

Susan: I come to HL from 24 years in Adult Literacy. We focus on a strength-based approach (rather than a deficit approach). We need to draw on our adult literacy background in relation to listening, speaking, numeracy, and writing. We need to collaborate and make sure all disciplines come through: We stand on and draw on a large range of fields. How do we use that, rather than reinventing the wheel, is the question.

Michael: We need to keep respect in the forefront. We need to bridge the communication gap with those of other cultures, backgrounds, etc.

Question: What are the areas where we haven’t gone and should go?

Rima: HL practice has not sufficiently ventured into public health. Our work has stayed within the institutions of health care. But we have to spend more time in the community, in homes, in workplaces, on key issues such as air and water quality. We should engage with people working in environmental health and others. We may need to be more qualitative and creative in our approaches. We need to get outside, breathe the air, and comment on it.

Michael: We should do as President Obama did: He drank the water in Flint, MI.

Susan: We need to hold a mirror up to organizations to get them to look at what they’re doing. Health care needs to give up its culture in order to work with the community, rather than just “doing things to” the community. We need to shift power.

The health care system in New Zealand is very different from the U.S. It’s much simpler.

Marin: After Fukushima, the Japanese government lost the public trust in 3 days. They have been investigating what happened. Together with a researcher in Boston, they got citizens in Japan to measure radiation levels. It may not have been ideal, but it engaged a lot of people and made data available. There is so much to be done with community engagement. “Active listening” is important to moving forward.

Cliff: We need to get out of our “silo,” get out of institutions and engage with the public. How do we describe what we do? It takes a long time. How do we get the public to understand and get excited about it and exert pressure from the outside? How do we teach the public to get excited?

Marin: Let’s get young people excited about the field.

Michael: We can collaborate with groups that work to make science understandable to the general public.

Marin: Alan Alda is using theatre games in his Stonybrook program to teach science.

Susan: Health professionals overestimate their effect, especially on chronic conditions. We have to acknowledge people doing a good job of taking care of their health, rather than just pointing out what they’re doing wrong.

Michael: Think about ways you can partner with other groups in your community.

Question: What obstacles and challenges do we face?

Rima: One obstacle was lack of scholarship, not learning from my colleagues. I had faulty assumptions about how to get there. It’s not a foot race, but rather walking with colleagues. Another one is lack of patience. A third is entrenched interests: We need to look at policy and policy change, and regulation of materials, testing of materials before releasing to public. We need to engage the policy sector to bring about mandates and regulations.

Michael: When we encounter an entrenched interest, we have to engage them in figuring out what we are trying to achieve with the barriers we have put in place, and how we can do better to achieve the overall goal.

Cliff: We have some catch-up to do in providing an evidence base for our work. Health care professionals won’t listen if there is no data. We need to show that HL changes outcomes for patients.

Institutionally, there’s no incentive for clinicians to get things right the first time. If the patient doesn’t get it the first time and has to come back for a second visit, the physician is rewarded for this.

Marin: There’s no funding to support policies. We need to look for opportunities for policies to have definition, funding, or at least some activities to support them.

Michael: What gets done first is what we get paid to do. There is funding for research into health literacy. There need to be incentives for the practice.

Susan: The code of patient rights in New Zealand says that the patient has the right to understand risk, but we’re still very bad at it.

Marin: We’re not successfully communicating risk. We have to find a real way to explain risk without scientific terminology. We need to show risk over time, pre-conditions: Understanding and explaining risk is a challenge.

Rima: Baric, an English health educator writing 30-40 years ago, said that we have the illusion that the notion of risk has the same power as the feeling of pain. Understanding risk is not necessarily linked to action. What we’re not doing is making the understanding of risk actionable: What can they do with the information?

Cliff: I need to be able to know when a nurse, physician or therapist is competent in clear communication. So that 10 years from now we can have measurable standards in our degree programs.

Rima: What can I do now to help us get where we want to be in 20 years? I want to work with young people, to pass on the mantle, to run with it, expand it, and change it. I want to work together, co-publish, work with young people.

Marin: 1 in 6 people in America have a communication disorder of some kind. We need to think of these people who need to have the health literacy models work for them. It’s more than translation or handing someone a form.

Susan: In the future, I want to share the generosity of my HL colleagues with the community – YOU, and with communities, as well as others in HL field.

From the audience: Janet Ohene-Frempong: We need to support providers in communicating clearly.

Cliff: We need to incentivize the practitioners to practice their HL skills with patients.

Marin: We need to figure out what incentives work.

Rima: We need a common language for scientists, practioners, and the general public.


Creating Your Own Health Literacy Program: Tools from the What To Do For Health Book Series

Gonzalez_smDiana Gonzalez, MPH, CHES
Institute for Healthcare Advancement

This pre-conference session will discuss lessons learned from programs implemented in 2015 surrounding IHA’s “What To Do” book series. We will explore the programs that were developed for the books “What To Do for Senior Health, “What To Do For Your Teen’s Health”, and “What To Do When Your Child Gets Sick”. Participants will learn health literacy tools and tips that could be used to develop new programs or enhance existing ones.

In this workshop, Diana provides an in depth look into how programs can benefit from health literacy principals. Participants were engaged in the workshop content through interactive group discussions and workshop participation. Items discussed included simple health literacy principals, provided examples of programs that include health literacy principals, how to apply health literacy principals to current programs.

Health literacy is defined as the degree to which individuals has the capacity to obtain, communicate, process and understand basic health information services to make appropriate health decisions.

Design Strategies


Patient information should we easy to read, simple, and clean. The following are myths (which are also mistakes) that individuals tend to believe are best when developing patient information.

  • More is better
  • White space is meant to be filled up
  • Fancy and fun font types are cool and good to use
  • Style should be formal
  • Art provides effective communication


The reality is that less is better, the more white space the easier it is to read and follow, stick with simple font types, style should be informal and written at a 3-5th grade reading level, although graphics are ok they must be limited and to ensure the item is conveying the right message.

5 Design Strategies

  1. Type  – the best font type is Serif for the body, San serif for the headings, at 12-14 font size, Avoid “ALL CAPS”, make use of high contrast
  2. Paragraphs – Use 1.2 to 1.5 spacing between lines, leave the right margin jagged, block paragraphs with no indents are best, one line return between paragraphs
  3. Chunking – helps to organize, keep similar ideas together, write things in a logical order, and use clear headings.
  4. Graphics – use to help in understanding, need to be simple and clear, not abstract, provide captions when appropriate, table and charts should also be simple
  5. White space – makes handouts less intimidating, helps to give the eyes a rest, use white space around paragraphs, graphics and pictures, etc.

Helpful Tips

Avoid ghosting – Ghosting is similar to using “watermarks”. Avoid using ghosting since it is not easy on the eyes and not easy to read.  Avoid reverse type – when white print is used on a colored background.

Writing Strategies

  • Use everyday words – plain language, kitchen talk, has a thesaurus and guidelines to help you
  • Avoid long, complex sentences – use about 10-15 words per sentence , if sentences are too long you lose the reader
  • Explain technical terms and use examples – sometimes you just can’t use plain language, but you can use a definition written in plain language to explain the meaning of the technical term, and perhaps give an example about that term.
  • Write in the active voice – active sentences are stronger, shorter and clearer. The person/object comes before the action.

Implementing health literacy principles

Senior Health

  • Belvidere, Illinois – Boone County Council on Aging requested a 1 ½ program about medi-care, fall prevention and home safety.
  • Used IHA’s booklet, developed into a power point
  • Conducted a train the trainer training (for Seniors)
    • Senior learning styles – identify your audience, who is your audience, who is going to be receiving this information, learning styles, what do they need, i.e. Seniors. Collect primary data if possible – go directly to the community (Seniors) ask what they need, what do they want to see, what would make them feel comfortable to sit in a classroom.
    • Tips for presenting: A good idea to get someone that identifies with that population/community.
    • Practice trouble shooting – met with the trainer and looked at goals together, asked what worked or didn’t work
    • A quiz was provided
      • What worked: handed out surveys, put the questions on the power point and questions were read out loud.
      • What didn’t work: it was too time consuming but beneficial for collecting the necessary data
    • Lessons learned – participants enjoyed the class, seniors enjoyed having a felling Senior facilitator, wanted more details on Medicare but there was only so much information than can fit in an 1 ½ workshop.

Teen Health – Using IHA’s “What To Do For Youth Teen Health” Book and “We Thrive” Curriculum

       Teen Health Book

  • Phone number list – front page for immediate reference, and easy to access, emergency/hotline phone numbers
  • How parents can help teens – provides information about how parents can help teens through the issues they may encounter
  • Teen issues – comprehensive list of teen issues such as:
    • Dating and sex
    • Teen Safety


The We Thrive curriculum uses IHA’s “What To Do For Your Teen’s Health” Book, the Adult Learning Theory, the Health Belief Model to help parents shift their way of thinking and behavior about their parenting style, also uses Health Literacy principals, and uses the five Youth Thrive Protective and Promotive Factors Framework.

The power point doesn’t use more than 5 bullet points per slide.

Youth Thrive Protective and Promotive Factors

  • Developed by the Center for the Study of Social Policy that demonstrates these are the factors needed to be considered successful and healthy
  • Youth Resilience
  • Social Connections
  • Concrete Support in Times of Need
  • Knowledge of Adolescent Development
  • Cognitive and Social Emotional Competence

Each of the above protective factors are difficult concepts and written in a high literacy level. The curriculum has rewritten them using health literacy principals. For instance, Social Connections is called Healthy Relationships in this curriculum.

This curriculum offers fun and interactive group activities that provide opportunities for parent participation, team building, conversation, role playing, and more.

Pilot Program – the La Habra Family Resource Center

  • 10 week program, small sample size of 6 participants, dinner and daycare provided
  • Lessons Learned – participants have a tendency to tell not ask, need to leave ample time for discussion, parents enjoyed speaking with other parents

Sick Child – Using IHA’s “What To Do When Your Child Gets Sick” Book

Sick Child Book

  • Different ways to search – headings and table of content that are easy read and use
  • Ages 0-5
  • Ears and nose
  • Mouth and throat
  • Stomach

Train the trainer training

  • At the 2015 IHA conference, with 30 participants, 4 hour session, class setting on how to use the book
  • Kansas Head Start: video was created and provided by the Kansas Head Start Association
  • Provides hands on practice
  • Uses a 5 step format
  • Lessons learned – can use more practical tools, participants enjoyed the video, want to know about programs for other books


Implementing the “Always Use Teach-Back” Training Program

Abrams_smMary Ann Abrams, M.D., MPH
Nationwide Children’s Hospital

Do you struggle with these challenges in your health care setting? How can I get everyone to use teach back? Why don’t patients do what we ask them? There’s just not enough time…this interactive workshop will use the “Always Use Teach Back! Tool kit” as a foundation to strategize on making teach-back an “always event”.

In this workshop, Dr. Abrams gives audience members the opportunity to begin thinking about steps that they could use to encourage their organizational leaders to promote health literacy and teach back.

This workshop also provides opportunities for group discussions about shared ideas, steps, successes and failures of using teach back.

Using Teach Back

Building it, creating it, refining it, evaluating it, seeing how well it works, and helping it sustain and actually make a difference on the front lines of patient care, how to get traction, and one that a lot of use deal with a lot is the resistance to push back and the fear of taking too much time.

After the training program, you will feel more empowered to advocate for health literacy and teach back. To help make that case, these are key elements of patient safety and quality care. To be able to use this Teach Back Toolkit and to build that into initiatives that you are using to make your organization a more health literate healthcare organization, and to support your colleagues and each other in changing individual provider behavior as well as organizational behavior when you increase use of Teach Back.

Making the Case & Leverage
Health Literacy 101

The chronology of building and integrating teach back in your organizational structure. To do this is through Health Literacy 101. Health literacy, the degree to which individuals have the capacity to obtain, process, understand, use health information to make appropriate health decisions.

According to the National Assessment of Adult Literacy Data, a third of adults have basic or below basic health literacy; only about 90% people lack proficient health literacy. The health system that we have is not well designed for 90% of people to use and function. Proficiency is not a high level of literacy, rather they are skills of things that are involved in assessing that are in the “now” or “everyday things” such as going out  seeing how much you need to pay for your insurance premium if you are a family of 4.

Low Health Literacy & Poorer Health Outcomes

This leads to less healthy behaviors, preventative care, personal health knowledge, and understanding of treatment choices. Poorer ability to demonstrate taking medicines appropriately, interpret labels and health messages, greater use of emergency care, excess hospitalization, increased mortality and poorer health outcomes. Higher health care costs from $106 billion to $238 billion, 17.6% of all Medicare admissions are readmissions within 30 days can cost up to $15 billion.

As a result of this data, health literacy is improving the skills of the heath care system collectively and recognizing that it is our (the health care industry’s) problem, not the patient alone.

Quality – A frame work for health literacy

Triple Aim is a framework to look at quality healthcare. Work to optimizing the performance by simultaneously pursing three dimensions: improving the patient experience of care; improving the health of populations and reducing the per capita cost of health care. The six dimensions (aims) that the Institute of Medicine report on patient safety, described safe and high quality care is: being safe, effective, patient-centered, equitable, timely, and efficient. Also seeing how health literacy intersects with those areas.

Drivers in the Transforming Health Care System

These drivers include the Affordable Care Act related initiatives, Accrediting & Regulatory Authorities, AGCME – all 6 competencies especially interpersonal and communication skills, Quality care & patient safety, and Risk Management. These are areas that are ideas needed to begin some conversations as to where you can gain some leverage and traction from leadership to implementing teach back.

Health Literacy: Quality & Safety

The AHRQ , Joint Commission, and the National Quality Forum  are some high level agencies and authorities, explicitly speaking about health literacy, and its relation to seeing effective care.

According to the Institute of Medicine Chasm Report, Health literacy is fundamental to quality care and relates to three of the six aims of quality improvement. These are safety, patient-centered care, and equitable treatment. Furthermore, the Priority Areas for National Action (for the U.S. healthcare system) identified that self management & health literacy are cross-cutting priorities for improving health care quality & disease prevention. These are some things to consider when planning your strategy to implementing teach back in your organization. Data also shows that low health literacy is more common among racial and ethnic minority groups; we are all increasingly seeing more diversity in our patients referred in our workforce which is another area of leverage that can be used.

What are some ideas you see for quality and safety and health literacy?

Ideas included medication management, self care instructions; i.e. chronic disease, and fall prevention, and discharge processes. Other ideas include readmissions, outpatient, care coordination, reducing health disparities, etc.

10 Attributes of Health Literate Health Care Organizations (Institute of Medicine Roundtable)

  • Leadership that makes health literacy a priority
  • Integrating health literacy into planning, evaluation, safety and quality efforts
  • Create a shame-free environment to meet the needs of patients
  • ensure easy access to health information and services; and navigation support
  • Communicate health insurance and health care cost information clearly
  • Include consumers in design, implementation and evaluation efforts
  • Prepare the workshops to be health literate and monitor progress
  • Use health literacy strategies in interpersonal communication to ensure and check patient understanding
  • Address health literacy at high-risk points
  • Design and use information that is easy to read, understand and use

Offering Solutions – Teach Back

Teach back is:

  • Asking people to explain what they learned in their own words what they need to know or do, in a friendly way
  • Not a test of the patient but a measure of how well you explained something
  • A way to check for understanding and, if needed, re-explain, then check again

Teach back – Quality & Safety

Several research studies have demonstrated successful results when using teach back. The Agency Health care Research for Quality, for instance, found that “asking patients to recall and restate what they have been told” is one of 11 top patient safety practices based on strength of scientific evidence. Others include:

  • Schillinger, et al., 2003 Closing the Loop
  • Bennett, et all., 2009 J Am Coll Radiol
  • Fink, et al., 2010, Annals of Surgery
  • Press, et al., 2010, J Gen Intern Med
  • Griffey, et al., 2015, J Commun Healthcare

Teach-back – Examples

Switching from YES/NO questions to Teach-back questions, such as:

  • YES/NO: Do you have your follow-up doctor appointment scheduled?
  • Teach-back:  Please tell me when your next appointment with your doctor is?

Teach back – is Everyone’s Job

This is not just for clinical providers, it’s important for everyone to know. Everyone that works in the health care industry need to use teach back in order to better help a patient through the journey of the healthcare system.

Unable to Teach Back?

If someone isn’t able to Teach-back:

  • Make sure they are using their glasses, hearing aids, or other assistive devices
  • Ask if they want to include family member or friend
  • Check for language, literacy, cultural barriers
  • Ask another health care team member to help
  • Schedule another visit or call

Then pass this information along to other members of the healthcare team, so that they are aware of the patient’s difficulty with teach back.

Changing Behavior

Never to Always

  • Never Event: adverse events are unambiguous, serious, and usually preventable (AHRQ).
  • Always Event: Aspects of the patient experience that are so important to patients and families that health care providers must perform them consistently for every patient, every time (IHI).

Make Use of teach-back an “always event”

  • Help all health care providers learn to use teach-back – every time it is indicated, to support patients and families throughout the care continuum, especially during transitions within and between care settings.

Making Teach-back an Always Event

  • High reliability organizations – organizations or systems that operate in hazardous conditions but have few than their fair share of adverse events: they are resilient, have a culture of safety.
  • Telling people to work harder doesn’t lead to lasting improvement
  • Education necessary but not sufficient: leads to low level reliability at 80-95% success rate so we want to make teach back a highly reliable intervention
  • Must use effective change strategies, as the individual and the organization.

Theoretical Models:

Transtheoretical Model of Behavior Change – worth applying this, so patients can be moved from the stage of pre-contemplation (to never hearing of teach back) to contemplation (willing to explore and think about it), then from contemplation to preparation (moving from Maybe to ok ), then from preparation to action to implement, revise/reform plan, (Ok I will use teach back). There is possible relapse and recycle piece with this model, therefore the need to go back to help though that issue.

IHI Model for Improvement – another approach for organizational change

This involves setting aims, establishing measures, and selecting changes to achieve that aim and making use of small tests of change. By starting small you avoid resistance. You are not setting high unrealistic expectations for the organization to implement of teach back.

The Always Use Teach-back! Toolkit

What Is In This Toolkit?

  • Introduction on Using the Teach-back Toolkit
  • Interactive Teach-back Learning Module
  • Coaching is Always Use Teach-back
  • Readings, resources and videos
  • Tools and Videos:
    • 10 Elements of Competence for Using Teach-back Effectively (PDF)
    • Why Use Teach back? A Patient Story – Inadvertent Overdose (Video)
    • Toolkit Background and Purpose (VIDEO)

Helping People to Always Use Teach-back

Raising Awareness & Changing Behavior – Applying Tips from the Toolkit

Traditional Methods

How to integrate traditional methods of implementing the tool kit:

  • Make it personal – connect to their experience or setting, a personal adaptation
  • Power of stories – talk about the successes
  • Close with a “call to action” – examples:
    • What can you DO by Tuesday?
      • Could you try using this plain language hand-out during discharge for one patient?
      • Would you be willing to try using teach-back with your last patient tomorrow?
      • Could you ask a family member for feedback to help you improve your registration process?

Marketing Strategies – an alternative to leadership resistance to teach-back

  • Explain the benefits – Highlight the importance of teach back
  • Then ask the questions:
    • How do you feel when patients don’t keep their follow up appointments?
    • Where do you see using teach-back as being most helpful?
    • How do you see yourself using this?
  • Handle objections – this is ok
    • They are interested enough to listen & think about it
    • Then restate it, reframing it
    • Clarify, if needed. Address concerns. Support your point. Validate their concerns
  • Close with a “call to action”: Willing to use it? Willing to try it?
  • Conduct some follow-up?

Coaching – Straight from the toolkit

  • Build motivation
  • Respecting and honor current work – all the hard work everyone is doing already
  • Understand and recognize that change is hard
  • Resistance is natural
  • Foster new skill development
  • Build confidence to integrate new habit into work plans
  • Make it a reliable process,  standard work; reminders; default; appropriate redundancy
  • Manage relapses: follow up coaching; share questions and problems; recognize and reward

Right Intervention for the Right Issue at the Right Time

  • Assess conviction and confidence
  • Create context to explore ambivalence
    • That’s interesting, tell me more
    • What makes you say that? Do that? Ask that?
  • Listen to and categorize resistance so you can respond appropriately

Overcoming Resistance

Right Intervention for the Right Issue at the right Time

  • Listen to and evaluate concerns to respond appropriately
    • If there is a lack of understanding, then explain, educate, check understanding
    • If they have a different perspective, then understand, acknowledge, perspective, address importance and inspire.
    • If there are competing priorities, validate, problem solve together
    • Focus on barriers, understand specifics, focus on their own behaviors, and seek their solutions, feedback. Formulate action plan.
  • Teach-back is an investment, it is NOT an add-on
    • Concerns about time – takes approximately 1.8-4.3 minutes more to the patient visit
  • Investment
    • Trade-offs/ Patterns/Habits – other people can help with teach back, have less interruptions, less non-compliance, less phone calls from people that don’t understand
    • Opportunities to improve outcomes

8 Steps for Organizational Change include:

  1. Establish sense of urgency
  2. Create guiding coalition
  3. Develop change vision
  4. Communicate the vision for buy-in
  5. Empower team and remove barriers
  6. Generate short term wins, communicate success
  7. Never let up
  8. Incorporate changes into the culture

Making it Stick

Sustain Improvement – adding teach back to parts of standards of care and clinical competencies which can be done in the following areas:

  • Position descriptions and performance reviews
  • Orientation and credentialing
  • Training and education
  • Build into care processes and competencies
  • Begin at admission, discharges are confusing
  • Order sets
  • Documentation systems for work flow, data feedback

Organizational Level

  • Quality meetings
  • Performance scorecards
  • Communication –related adverse events
  • Lay reader review in materials development
  • Faculty teach, model, and evaluate for learns
  • Recognize leaders and champions
  • Engage community teach how to elicit teach back

Focus on high-risk situations such as medications, transitions


  • Know when and how to access and work with trained interpreters
  • Passes along need for clear communications (SBAR)
  • Can “stop the line” if they sense a patient/family member doesn’t understand
  • Ensures understanding with teach back

Using Teach Back Well

Chunk and Check

  • Teach 2-3 main points for the first topic
  • Check for understanding with teach back
  • Then go on to the next topic
  • Support teaching with reader-friendly print materials
  • Use teach back for all key patient education and communication
  • Document use of and response to teach back


Writing and Designing Effective Communication: A Comprehensive Course

From left to right: Janet Ohene-Frempong, MS, Jann Keenan, EdS

From left to right: Janet Ohene-Frempong, MS, Jann Keenan, EdS

Jann Keenan, Ed.S & Janet Ohene-Frempong, MS, IHA Strategic Partners

Jann Keenan and Janet Ohene-Frempong gave a daylong workshop on strategies for communicating effectively with constituents through both print and online materials. They used many samples created throughout their careers to illustrate what works and what doesn’t work. Ohene-Frempong stressed the health communication and health literacy must incorporate a reader-centered approach. This is the best way to engage, support, and motivate readers. They offered tips for how to implement this approach in both writing and designing materials in different media.

The presenters discussed how to write effective materials by offering tips on content, organization, and style. They also discussed effective design and page layout techniques to engage readers and increase understanding. If you aren’t designing your own materials, then it’s important to raise awareness in your designer about why design needs to be done a certain way. Keenan emphasized that an early buy-in from all partners in the creation of patient materials is key to creating health literate communication.

The presenters explained how to assess the readability of text and design and explored how to use readability tools and field-testing. They discussed how to revise text and design to improve readability. They also coached participants on how to plan a writing project. They encouraged attendees to be advocates for their readers. If there is crucial information you want to include, but limited space, the writer must fight to keep content that will benefit the end-user.

The workshop included two group exercises: a writing exercise and a revising exercise. The presenters led the group through the exercises step by step. The main take away from the session was that we must write for our readers and end-users. Being focused on the end-user is crucial to the creation of clear and effective communication.

User Centered Design for Audiences with Limited Literacy Skills: An Introduction to Research and Testing Methods for Print and Online Materials

Xanthi Scrimgeour, MHEd, MCHES

Xanthi Scrimgeour, MHEd, MCHES

Xanthi Scrimgeour, MHEd, MCHES & Stacy Robison, MHEd, MCHES, CommunicateHealth, Inc.

Xanthi Scrimgeour and Stacy Robison facilitated a pre-conference workshop titled, “User Centered Design for Audiences with Limited Literacy Skills:  An Introduction to Research and Testing Methods for Print and Online Materials.”

The definition of User Centered Design (UCD) was provided as “Involving end-users (your audience) in the design and development of a product, message, or campaign.”

Stacy Robison, MHEd, MCHES

Stacy Robison, MHEd, MCHES

The workshop focused on the following:

  • Steps to the User Centered Design process (Co-creation, Participatory design)
  • Methods in getting to know your audience (or clients) in order to involve them in serving as “co-creators” in designing key marketing tools to be used by actual clients
  • Methods to conduct user research and organizing information gathered
  • Testing Methods for getting feedback from your target audiences
  • How to involve participants with limited literacy
  • Ways to save time and money on user research and testing

The facilitators provided 5 reasons to involve your actual “audience” as part of the co-creation/participatory design:

  • Just because you think your material is awesome doesn’t mean that your audience has the same opinion.
  • You can waste a lot of time and money developing materials and products that your actual audience will not use.
  • Involving your current audience will allow you to assess whether or not your messages will be understood.
  • Target audience members will be empowered and invested in the success of your product.
  • It will make you a better communicator.

Both facilitators discussed the importance of talking directly to your audience (client, patient, etc.) to create “personas.”  Personas are created based on a mix of people.  It is based on actual research with your audience to prevent the persona from being a “stereotype” – and not necessarily related to people.  One can achieve creating this step by performing focus groups, one on one client interviews, collage exercises, etc.  It is important to also create a specialized group of individuals (recruits) to develop personas.

Our facilitators engaged attendees of the session in interactive exercises to further describe and understand the value of creating personas.

Best Practices for Health Insurance Outreach, Enrollment, Retention & Utilization: A Train-the-Trainer Session

Amy DeMarco, MPA

Amy DeMarco, MPA

Amy DeMarco, MPA, Institute for Healthcare Advancement

Amy DeMarco led this interactive train-the-trainer session on the OERU model (Outreach, Enrollment, Retention and Utilization) for coordinating health care access for the uninsured and newly insured. This model was originally created for the Healthy Families Program, also known as California’s State Children’s Health Plan. Best practices on how to reach and engage the uninsured were introduced in conjunction with experience-based guidelines on how to enroll consumers into health care coverage through a healthcare marketplace, like Covered California, California’s state-based healthcare exchange.

DeMarco stressed the importance of following up with clients and how getting them in for an appointment may require different techniques. She also shared tips on personalizing  documents for clients  such as highlighting keywords, writing the clients name, and underlining important information to help them retain and act on the information provided. Attendees were asked to share what works best for them and what has received a positive response from the client.

Difficult health care terms were explained in plain language. The presenter also ran through several common enrollment scenarios and asked participants to role play as the CEC and the client. Then these scenarios were discussed in the larger group so attendees could learn from others’ experiences.

Emphasis was placed on the Retention and Utilization portions of the trainings because there has been a great push by the marketplaces to increase enrollment, but little support provided to enrollers or healthcare workers to help these clients use their coverage and retain their insurance long term.  Suggestions for helping clients remember to pay their bill each month and renew their coverage each year were discussed. Reasons and solutions for why clients might not retain their coverage were also discussed.

Using the teach-back method was suggested to help clients understand their coverage and what they need to do to keep it. The Ask Me 3 technique was an audience suggestion on how to ensure that clients understood the health insurance information provided to them. This technique  helps enrollment counsellors identity the client’s main concern , develop next steps for the client,, and establish why it is important for them to take these necessary steps to get, keep and use their coverage.

The Utilization section kicked off with role-play scenarios where an audience member explained to a client how they could effectively navigate the healthcare system to use their coverage. The different types of care were discussed and the presenter explained in plain language terms the attendees could use with clients to explain when go to the ER, urgent care, and primary care provider (PCP) and how seeing their PCP first in non-emergency situations could save a client money.

Collaborative Approach to Testing Materials: A New Industry Paradigm

Left to Right: Kara Jacobson and Heather Turkoz

Left to Right: Kara Jacobson, MPH and Heather Turkoz, M.A.

Heather Turkoz, M.A., Merck & Kara Jacobson, MPH, Emory University

Heather Turkoz and Kara Jacobson used their experience to illustrate to other healthcare professionals how a collaborative approach to testing can create highly effective health communication material. Their collaboration is a case study on how a company, like Merck, can partner with a diverse set of stakeholders, like Emory University and Northwestern University, to improve its patient communication. In this case they partnered to improve Merck’s patient labelling process through evidence based market research facilitated by Emory. Their collaborative approach included the application of health literacy principles into a newly designed patient package insert and implementing new market research methodologies to solicit and incorporate feedback from respondents of all health literacy levels.

After implementing health literacy best practices into the patient package insert, research showed that the average comprehension scores were 93% across all subjects with no meaningful differences between those with limited health literacy and those with adequate health literacy. Turkoz and Jacobson provided new perspectives and insights on a model for building an effective partnership between industry and academia to affect real change and improvement in health literacy.

In order to develop patient labelling that was well understood and actionable, application of best practices from the field of health literacy was required. These methods are commonly used within the field, but not within the pharmaceutical industry. These included identifying and recruiting patients with limited health literacy into the research and refining the methodologies to assess comprehension of medication information. The presenters also emphasized the importance of including an iterative method to incorporate patient and caregiver feedback into the development process of patient communication. The recruitment and screening techniques for populations with limited health literacy were shared and can be applied by participants from other large organizations within the health industry. Furthermore, their testing methodologies can be used with a broad range of patients, inclusive of all health literacy levels. Lastly, they shared implications for future development of patient communications that go beyond the patient package insert.

How to Use the Book ‘What To Do When Your Child Gets Sick’: A Train-the-Trainer Session

Diana Gonzalez, MPH

Diana Gonzalez, MPH

Diana Peña, MPH, Institute for Healthcare Advancement

Diana Peña’s preconference session began with a brief introduction to the Institute for Healthcare Advancement and the production of their “What To Do” book series.  The book “What To Do When Your Child Gets Sick” was chosen for the training since it is the organization’s flagship book.  She then gave an introduction to the mock training with a discussion on how a trainer would prepare to administer the class. She mentioned strategies to increase the probability of a successful class such as providing childcare and sending reminders to participants.

The mock training was delivered as though Peña were facilitating training to consumers who would use the book at home with their families. The training began with a video created by the Kansas Head Start Association.  The movie gave expert insight on the effectiveness of the book as well as its utility for parents. Later participants were introduced to the easy to use format of the book and practiced using the book with real life scenarios.

Lastly the train-the-trainer model was delivered as though the participants in the session were trainers for the book.  Peña reviewed subject matters needed to deliver an effective session such as health literacy, culture, and adult learning.  She discussed the importance of understanding and teaching in a manner that acknowledges the health literacy levels of adults.  Participants were then given the opportunity to practice two techniques that acknowledge participant health literacy levels, teach back and plain language.  The remaining of the session focused on managing classroom situations such as too many question, limited time, and managing disagreements.

Discussion on managing classroom situations allowed participants to share experiences and knowledge as well as brainstorm new ideas.  The session ended with a wrap up activity that brought all ideas together.  Participants were to pick a section of the book and use plain language to describe this section to another participant.  Then participants checked to see how well they explained the section by using teach-back.  This was a great way for participants to practice with the book as well as practice newly learned skills.