Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud. In these podcasts, you get to listen in on my conversations with some truly remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.

Today I’m talking with Paula Griswold who is Executive Director of the Massachusetts Coalition for the Prevention of Medical Errors, a statewide, public/private partnership to improve patient safety and reduce medical errors.

Paula has led many important collaborative projects, including reconciling medications, preventing medical errors, preventing infection and reducing hospital readmissions, all while improving a patient’s experience of care.

I’ve known Paula as a colleague for many years. Our interests have always been somewhat similar, but it’s only lately that they seem truly overlapping. Welcome, Paula.

Paula: Thank you so much, Helen. I’m really delighted to be here.

Helen: What’s your take on how patient safety and health literacy are coming together?

Paula: It’s becoming clear that health literacy and effective communication between a patient and their clinician is absolutely central to patient safety. We’ve seen it in the inpatient setting, and more and more now, we’re understanding in the physician office visit how many opportunities there are for potential harm to patients if there isn’t effective communications.

Helen: Can we take this from the top? We’re talking about two different sides of this. Central to this is communication or some component of health literacy, but you’re talking about patient safety. You’re also talking about harm. Can you give some examples to what you mean by patient safety?

Paula: There are the serious concerns if the patient leaves the office visit without understanding the instructions. They may be taking the medications wrong, they may not take their medications or they might end up taking two different drugs that are performing the same function, so they end up with an overdose. The elements of communication are central to the patient receiving exactly the right treatment.

Helen: The right treatment is the goal with all the work we’re doing. You say communication is part of the core of what could be some of these serious concerns. When you say patient safety overall, is that the opposite of those harms? Is it just taking medication correctly and the right amount at the right time?

Paula: That’s right. We use the term “patient safety” sometimes because clinicians are uncomfortable talking about harm and they don’t like to think that they may be harming patients during medical care, but that’s exactly right.

Keeping patients safe effectively involves understanding what their needs are, what their symptoms are, what their family history is and working together with them to come up with the right treatment plan that will address those.

Sometimes I’m uncomfortable with the term “health literacy” because sometimes in talking to clinicians, it gives the impression that it’s really the patient’s problem, the patient’s lack or the patient’s gap.

Communication is a two-way street. There is really the need for the clinician to make every effort to be understood and listen and ensure that the understanding occurs in both directions.

Helen: Can I just clarify some communication too? You raised a really important point. You represent a large group of people as you do all of your collaborative work, but you see health literacy as about the patient’s abilities or lack thereof.

Indeed, the definition of health literacy is expanding to look not just at individual learning needs or barriers but also the healthcare systems, the complexity and the demands. It’s really working toward the alignment between the two. Is this a message we need to get out more? That would help you in your advocacy work too.

Paula: Absolutely. As I say, I have no concern about the field. As you’re describing it, absolutely that’s my understanding. I’m simply saying that sometimes in the discussions with clinicians about health literacy, the implication that they might take is, “Oh, this is about the patient’s understanding.”

As you say, it’s much larger than that. Yes, I think that the efforts of your organization, your activities and these podcasts are super because it is a much broader topic to be addressed and not simply a matter of the patient’s understanding.

Helen: That’s really true. We have some work. Maybe we will forge some paths together, and not just our worlds overlapping a little bit but maybe overlapping more to frame what we are both talking about.

Thanks, Paula, for making clear and giving some examples what issues we’re talking about and some problems we’re facing. What do you see as some solutions? How can we help improve patient safety, especially through effective communications?

Paula: We’re very excited about the potential of informing not only the clinicians but all staff who interact with patients about the importance of the issue and ways they can ensure in their daily work that they are hearing the patient’s concerns and that the patients are being effectively understood. They’re also reaching conclusions together and providing instructions in a way that the patient and family understand.

There are real simple techniques that are not necessarily taught in medical school and not necessarily even always taught in nursing school, but there are basic strategies that can be really valuable in improving effective communication in both directions.

Helen: Give us some examples.

Paula: There are things like teachback for giving instructions. If the patient is being told something about how to take their medication or how to use an inhaler, the classic problem is running through those instructions, looking directly at the patient and saying, “Do you have any questions?” Most of us, eager not to seem stupid or to show that it wasn’t that complicated will simply say no.

Frankly, the clinician may talk about these things every day and not realize that this is completely new for this patient. A more effective approach may be to say, “I want to evaluate how well I explained that to you, so can you just tell me your understanding of when you go home how you’re going to use this inhaler?” or “If you were going to explain it to your husband when you go home, in your own words tell me how you’re going to use this inhaler.”

There is often the chance to discover, “That’s certainly not what I wanted to be understood from that.”

Helen: What you’re talking about, Paula, is a key point that we make in health literacy. When I make my presentations and talk to providers, I talk about teachback too. I think our worlds are more than overlapping at that point. We are going to the same place when we give recommendations like teachback. I’m delighted that in your projects you’re focusing on that too.

Are there other strategies you’ve learned through your research or your collaboration that we just need to know?

Paula: One thing is having an understanding of how to talk about a medication list in a way that is going to be more meaningful to the patient. Again, it often involves being sure to listen and let the patient discuss it in their own words.

Do they have an understanding of why they’re taking a medication and any danger signs to watch for or necessary monitoring associated with it? It’s sort of a special category of teachback.

Helen: Yes, it is. When we talk about medication reconciliation, is that what you’re talking about or is that something different? I know about that brown bag and about bringing your medications with you. Is that the conversation you’re focusing on, or is this a little bit more nuanced?

Paula: It is that exactly. When a patient arrives at the hospital these days, they often might be coming in for a surgical procedure but they’re already on four or five medications for a set of medical conditions. The first step of the process is to make sure that your care providers at the hospital know what you’re taking.

Unfortunately, we all have been assuming that the medical care system passes that information around and knows about what providers we’ve seen and what medications we’re taking, but it’s not running that smoothly yet.

The first step in reconciling is for the healthcare system to know what you’re taking. The second step is, in the course of care for the clinicians, to be thoughtful in making sure that any medication changes are accurate and you’re not ending up with some therapeutic duplication on the list that’s given to the patient.

The final step of that is not only good teaching but good two-way communication to see when you go home, do you know what you have at home that you should stop taking? Do you know what to start taking? Do you recognize the medications you’ve been taking by the names that we’re using? Do you know exactly why you’re taking them?

Medication reconciliation is just a particular special case which is unfortunately a high-hazard situation. Patients these days with chronic conditions can often be on 16, 17 or 18 medications.

You can imagine with different brand names, generic names and with the hospital using a different name than the version than your insurance company covers so you’re being told to take something with a name that you’ve never heard before, there’s a potential for some really terrible confusion. As I say, the case of medication can really be quite harmful to the patient.

Helen: I really like how you laid that out in those three steps. Again, that’s the two-way communication. It’s not just the patient and it’s not just the provider. It’s the alignment between the two. Are there resources where people could learn more about that process as clearly as you just explained it to me?

Paula: Yes. We do have information on our website. It’s www.MACoalition.org. We have a patient-friendly medication list that’s laid out in a way that’s also intended to encourage and provide prompts for some important discussions between the patient and their clinician as they are getting a new medication prescribed.

Helen: That’s wonderful. Is that available to everybody? Can our listeners use that and take that in their own work whether they’re in Massachusetts or anywhere else?

Paula: Absolutely. There’s a free download from our website. It’s called The Med List.

Helen: That’s perfect. We will have that link on the Health Literacy Out Loud website too. Paula, I’m looking at many of the projects that you’ve worked in and some of the high points. I introduced you for talking about preventing medications errors, preventing infection and reducing hospital readmissions. Those are gigantic topics lately that I know I’m getting many questions about too.

They’re asking, “What can we do about this? How can we improve this?” Could you talk about some information that you’ve learned through your many research projects about that? If I had to pick one, I would focus on reducing hospital readmissions. How does communication factor in there?

Paula: It’s particularly crucial. In the work that we do in our organization, we highlight that transitions of care are frankly one of the highest risk times for patients.

Helen: Are you talking about all transitions, like when you go from one unit to the other, the hospital to home, from the home to the nursing home or from the nursing home to home care? Is that what you mean by transitions?

Paula: Yes, it’s especially from one setting to another. Hospitals have been doing a great deal of work on improving handoffs so that they are more likely internally to be getting the correct information about what’s happened and what needs to happen, but the continuing challenge from the perspective of risk to patient is when suddenly no one is in charge.

The hospital has discharged you and perhaps even set up an appointment with your own physician for later that week, but in the meantime you’ve been given a lot of instructions that your physician may or may not even be aware of. You might have a new diagnosis that your physician hasn’t even received the discharged information about yet.

That also ties back to the discussion we were just having where you might be started on new medications and there might be side effects. If you want to ask a question about them and call your physician, they may not even have all of the information yet about that hospitalization.

Helen: I’m getting chills listening to this.

Paula: I’m actually getting a little worried that I’m going to frighten people about getting medical care.

Helen: I can relate to all of that with any experience I can think of. That’s like walking on a tightrope with no net for a while until you reach the other side and you’re finally back in your outpatient realm. What can all of us do?

Paula: The good news is that all across the country, hospitals and post-acute care providers in their communities and the physician offices in their communities are now addressing this much more specifically because this has been identified as a significant patient-safety problem as well as a contributor to higher costs.

If something goes wrong and the patient ends up not being able to fill a prescription, being confused or taking two doses that ended up being the therapeutic duplication of the same medications and end up back in the hospital, it’s not good care. It certainly is far more expensive than if it went smoothly to begin with.

All across the country, hospitals are working on how they can take responsibility for the handoff as the patients are being discharged from the hospital to the skilled nursing facility, to home healthcare or to home, and that information is more quickly and more effectively communicated to the physician who is going to be picking up the responsibility.

Helen: As you are articulating that, it is getting even clearer to me why you said that the hospitals have to take responsibility for that handoff. That’s the gist, I’ll bet, for the lack of reimbursement for a hospital readmission within 30 days, right? It’s the great big healthcare reform, or some big body is saying that hospitals are responsible where it used to be that nobody was responsible.

Paula: That’s right. The problem had been that the Medicare program, the payment system and the incentives created by the Medicare payment system often determined behavior in the entire healthcare system.

For many years now, the motivation has been to shorten the length of the hospital stay because the hospital wouldn’t be paid any more money if the patient stayed a few more days.

Unfortunately, what that might contribute to is not putting quite as much time into the discharge planning and not spending quite as much time when the patient was feeling better and better able to follow the teaching and learn the self-care.

Since there wasn’t an expectation of how information should be communicated to the next site of care and making sure that the skilled nursing facility, the home health agency or the physician in the outpatient setting who was going to be picking up responsibility had all of that information promptly, those were gaps that remained.

These new Medicare incentives, such as the approach of having penalties if readmission rates are higher than the national standards, have really changed how the hospitals are thinking. They may not have thought it was their job before, but they’re recognizing how crucial it is to good care and working more specifically on all of those processes.

Helen: Paula, you’ve framed that in the clearest way I have heard yet. Thank you for that. Our listeners are all interested in health literacy in some version whether they are clinicians, public health or even librarians, family members or caregivers. We run the gamut there.

I know you’re saying it’s a hospital responsibility, but I think we’re all part of this picture. How can we help?

Paula: We’re very much advocates of preparing for any encounter with the healthcare system and carrying a medication list. We would like to think that the great internet in the sky is connecting all of our medical records, but it’s not yet.

Showing up at your specialist visit or after your specialist visit at your doctor’s office or after your hospital admission at your doctor’s office with a complete list of medication is helpful. Include any notes about what changes you’ve made, such as, “This one makes me dizzy, so I only take it every other day.”

Don’t be afraid to speak up and acknowledge when you have concerns or if you have something recommended. You need to say, “I actually am not willing to go get that colonoscopy,” or express your concerns and say, “I feel reluctant to get that colonoscopy because of what I’ve heard about it from friends.”

Instead of just walking out of the doctor’s office, nodding your head and acting as if you were going to call the GI and set up that appointment right away, you should speak up. I’m always hesitant because I don’t feel like the healthcare system should make this the burden for the patient. It’s definitely fine to be a shyer, less assertive person. The healthcare system should still provide you good care.

Helen: I’m so glad you’re framing it that way because it takes so much courage to speak up, especially when you’re sick and feeling so vulnerable.

Paula: That’s right. On the other side, the clinicians should absolutely be saying, “We know that sometimes we are recommending something that you may have concerns about. I don’t want you to think that I’ll think you’re a bad patient if you want to discuss those. It’s really helpful for me that if you wouldn’t want to take that statin or if you don’t want to go for that specialty visit, we could have that discussion.”

The clinicians need to go ahead and acknowledge and encourage the conversation and not just stand there with their hand on the doorknob saying, “Is there anything else?”

Helen: That’s right, or, “Tsk, tsk, tsk,” if you didn’t ask or if you didn’t raise that question.

Paula, I get that real true sense from you that you are sincerely embodying that two-way conversation and that it’s nobody’s fault. We are all in this one together. I thank you for helping lead the way statewide.

I think that statewide there are some national projects of how health literacy and patient safety are working in tandem toward the same goals.

Paula: I have to admit that I have a huge amount of sympathy now for the clinicians. I heard a description recently from Jim Conway.

Helen: Jim Conway was at Institute for Healthcare Improvement.

Paula: Yes. He’s been a leader in patient-centered care and patient safety for many years now. Jim has also been traveling around the country and listening to the workforce talking about what it’s like practicing in healthcare these days.

This nurse was describing to him how she comes to work every day and she feels like she’s at the bottom of the waterfall with this stream of expectations and new demands coming down on her.

Jim was describing how much that image has resonated as he has talked in other settings, so I do have a huge amount of sympathy for clinicians in healthcare. This is not just their personal burden to fix. We really do need leadership and policymakers across the system acknowledging the challenges that are there and supporting the individual clinicians.

This can’t just be, “Scold, scold, scold, you’re not communicating well. Go out and fix it. By the way, you won’t get paid for your HEDIS measures because your patients are not getting these preventive services.” We really do need more supportive strategies that provide the training that helps make sure that the time is available and that scheduling is appropriate.

Sometimes we hear from the clinician, “I understand that I should give more time and make sure that I am letting the patient express all of their concerns. I am booked in 12-minute visits. How can I do that?” It may be unreasonable to keep scheduling 12-minute visits when it would be recognizable in advance that some of those patients are coming in with very complicated or very serious needs.

We really need systems solutions, and I don’t mean to make this just seem to be scolding or blaming the individual clinicians. It’s another example of how we need system-wide solutions and leadership to get there.

Helen: Paula, I thank you for that, too, your sensitivity to what it’s like for people doing the day-to-day work. Everybody goes into doing what we’re doing because we care. We want to make things better. You’re right. People can just feel so beaten down and beaten up. Thank you for that sensitivity, caring and even more for being a true health-literacy champion.

Thank you for sharing all of that with the listeners of Health Literacy Out Loud.

Paula: It’s delightful to have the opportunity to talk about it, and I appreciate all of your supportive comments, Helen. This is just such a passion of mine that we improve the healthcare system for all of us as well as for all the patients and families who need the services and for the clinicians and staff who went into this because they are so concerned about patient care.

Helen: Thank you, Paula.

I learned so much from that conversation with Paula Griswold, and I hope that you did too. Health literacy isn’t always easy. For help communicating your message in ways people can understand, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, sign up for the free monthly enewsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, on Stitcher Radio and on the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.com.

Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.