Helen Osborne: 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 about health literacy with some really remarkable people.

Today, I’m talking with Barbara Balik, who worked as a nurse practitioner before moving into leadership roles as a Chief Nursing Officer, Executive Vice President and then a CEO of a large healthcare system.

Barbara cofounded Aefina Partners, an organization committed to healthcare transformation through partnerships among healthcare leaders, physicians, team members, patients and families.

She’s on the Senior Faculty at the Institute for Healthcare Improvement and a member of the National Patient Safety Foundation Board of Governors.

Barbara and I met in person many years ago and we’ve recently reconnected through our shared interest in health communication.

Welcome, Barbara.

Barbara Balik: Thank you, Helen. How are you?

Helen Osborne: I’m great. I’m really interested in talking to you because you’re wearing a couple of, shall I say, hats.

You do have a strong clinical background. Those are the folks I hang around with most, clinical folks, public health, librarians and those of us on the front lines of health communication.

Your other hat is as a Senior Healthcare Executive. Honestly, that’s an audience I find much harder to reach.

Putting on both your caps at first, from your perspective why does health literacy matter?

Barbara Balik: That’s a great question. As you well know and as the people who listen to your podcast know, health literacy is really the essential foundation for partnerships with patients’ families and community members. If we don’t have a mutual understanding, we’re not going to make the progress that we need in healthcare.

Helen Osborne: I’m going to stop you right there because I’m curious about those partnerships. You’re talking about partnerships with all the key players. Show us. Paint a story for us. Tell us a story. What would that ideal partnership look like?

Barbara Balik: I think about partnerships at three different levels. The first, as you’ve mentioned, is the people that you like to hang out with, and where I come from, they are those who have the closest relationship with patients and families. That’s the first level.

You may be a clinician and you may be interacting with the patients and families on a daily basis, so health literacy is absolutely essential at that level to be able to have mutual understanding so that patients and families can understand what I’m saying as a health clinician. I also understand from their standpoint what their values and knowledge about their lived experience are about.

The second level is, when we’re looking at our clinic or our in-patient department, how do we interact with all the patients and family members that we see?

Helen Osborne: With your whole population you’re treating?

Barbara Balik: That’s right. How do we set up our clinic or our department so that health literacy is woven through so that we always are working on better mutual understanding?

That includes the materials we use, the signs we have posted and the terminology we use. How do we ask patients and family members, “What matters to you?” as a way of understanding their needs.

The third level is more the hat that I would wear as a Senior Executive, which is at the policy-making level. Who’s at our Board of Director’s meetings? Who in the community do we have as partners or community members that can help inform us as far as what needs are in the community and how we improve?

Those are the three levels I think of as far as being invaluable for health literacy as a foundation for partnerships.

Helen Osborne: I totally get it and I totally agree with you, but looking back on my experience back in my hospital days quite a while ago, I got it as a clinician.

I was also a department manager and other new department managers got it too. But the senior leadership didn’t. I’m frustrated to this day that I could not get through to the senior leadership at the small hospital I worked at.

Tell us, what can we be doing? I was frustrated and still am. How do we get through to people at that senior level of influence?

Barbara Balik: I think of six different steps. I broke it down into smaller pieces. The first thing I think about is how do you make the case for health literacy?

What’s going on right now, and it has been for a while but it’s even accelerated, is there are so many competing demands and so much noise in our environment.

Everybody is feeling that, but especially senior leaders. How do you sort through what’s important today and what maybe can wait until next year?

I think the first thing is to recognize the continued demands and a lot of noise.

It’s also recognizing, which is about understanding your context, that health literacy is unknown to many leaders.

Helen Osborne: It still is? It wasn’t just 20 years ago?

Barbara Balik: Yes. Unfortunately, it still is in my experience. For many of us, and I’ll put myself in those shoes, you often don’t know what you don’t know. When someone approaches you about something that’s as vital as health literacy and you don’t know what you don’t know, it’s easier to dismiss it than to understand what’s going on.

Helen Osborne: When I think about my experience, I think that probably was part of it.

As we’re going through these, I know you have six things that we can be doing. I’m tempted to ask you to give an example for each, or would it be easier to talk about all of these and then put it all together for us?

Barbara Balik: Maybe I’ll give a few examples here and there and then you remind me if I’ve forgotten. Why you need to make the case is the first one. It’s just recognizing your context.

What I have found in my own experience is someone would come to me about something that I later finally got was really important, but the request was too vague. It was more hint and hope, as we sometimes say, or it was too big and broad.

The one we’d always chuckle at is someone would come and say, “Barbara, I need your support.” I’d say, “You’ve got it. I’ve got my football uniform on. Now what do I do?” It’s being more specific.

First understand that the leaders you work with, both your peers and those in senior leadership roles, may not know what they don’t know.

The second is to link it to strategy. You should be very clear on what your organizational strategic plan is and what the goals are for this year. If you’re not, go looking for it before you start trying to propose work in health literacy.

I always think about statistics and stories. There is a lot of good data on the vitalness of health literacy and there are some marvelous, powerful stories, probably within your own setting, those through your website and those that they can find online. Unfortunately, evidence or data alone often isn’t compelling enough.

Helen Osborne: Is it right that the stories alone may not be justification enough?

Barbara Balik: That’s true. Stories without the stats lack the meat and stats without stories lack the heart.

Helen Osborne: You’ve got all these wonderful phrases.

Barbara Balik: You need to make the statistics come alive. When we say 50% of US Americans barely can read at the eighth-grade level education, what does that look like? In the stories I tell, it may look like my dad who had an eighth-grade level. My dad struggled with certain things.

In hindsight, he developed marvelous coping mechanisms, but without knowing that, you would swear that my dad was the most proficient at just about everything, and he was. He just wasn’t very skilled in some of the things above that reading or mathematical level.

Helen Osborne: I’m so glad you’re honoring that story and thank you for telling us about your dad. I find that so powerful to tell the stories, but then to back it up with stats. I’m glad you’re a champion of that too.

Barbara Balik: You might use a statistic and then say, “Here’s what it looks like,” and tell that story and then link it.

If you have a strategic goal to reduce readmissions, there’s always a story if you have interviewed patients who have been readmitted.

I have great colleagues. Gail Nielsen is one.

Helen Osborne: I know Gail. We’ve done a podcast with her on the teach-back technique.

Barbara Balik: One of her tools in teach-back is interviewing patients and family members in a very respectful, non-shaming way about “Why do you think you had to come back to the hospital? What is it that was missing that we could have helped with?” Often, you’ll find a health literacy cause.

Helen Osborne: That’s really making that case using the stats and stories and applying that to the strategy.

Barbara Balik: That’s the second one. The first one is understanding your context in the noise that your leaders are working with. The second is link to strategies using stats and stories.

These all flow together. The third is what’s the purpose? I always say, “Can you explain in 20 feet walking down the hall why health literacy is important?” You can’t. People get lost in the verbiage.

I got some great advice one time from a colleague that said, “Just because you know it, Barbara, doesn’t mean I have to hear it.” What are the key points at this stage that I need to know?

Helen Osborne: Key points, which is what we know in doing our health literacy teaching, is that a person can only retain just a limited number, such as three or four points.

Barbara Balik: Exactly.

Helen Osborne: Do the same even though we’re talking to senior executives.

Barbara Balik: That’s right. Remember, my definition that builds on yours is that health literacy is about mutual understanding. If the person I’m talking to is very well educated, but doesn’t understand what I’m talking about, we’ve got a gap there.

Helen Osborne: Good. You’ve made your point clearly. I’ve heard it called an elevator talk, but you’re more on the ground, so it’s while you’re walking down the hall.

Barbara Balik: Let me tell you about this. Here’s where you play into it. That’s the third step I think about.

The fourth is build alliances. Before you try to start engaging too many people, find out who your people are. Who are your champions that work with you? As we say in patient safety world, never worry alone.

Helen Osborne: I like that.

Barbara Balik: If you’re trying to carry this by yourself, that’s too big a burden. This is too big and too important work to do it alone. Identify what I call champions and partners.

The partners may be peers that you have who get it, who are enthusiastic and who are willing to do good things. I always look around for who your peers are that are really accomplished in doing a lot of other things.

If you’re successful, for instance, as a Department Director or a manager, you’re more likely to be listened to by others, so look around for your partners.

Secondly, identify who could be champions. You may already have somebody. I always look to the clinical executives first. They sometimes have a quicker pickup on this one. They would be the Chief Nursing Officer or Chief Medical Officer, and if you have a Chief Quality or Safety Officer, that’s a logical link for them.

Helen Osborne: Patient experience, too.

Barbara Balik: Absolutely. It could be any of those.

Helen Osborne: I want to ask you a couple of practical questions as you go through this. What about the timing of that? It sounds as though you have to do your homework before you approach the Chief Executive. You’re talking about lining up your support who believed in this along with you.

Would you wait to get everything just so before you had that hallway conversation or office conversation with the Chief Executive, or might you start earlier in figuring out as you’re going through?

Barbara Balik: I think you’re hitting exactly on it with the latter point, Helen, which is that you build engagement around a key topic through a series of conversations.

The conversations are first about the purpose, so start with why. Have multiple conversations and identify some of the assets that you have built on strengths.

Always build on strengths. You can point to, “Gosh, my colleague Helen is doing this amazing work over in the OT Department and it’s a shame we’re not doing it everywhere.” Identify some of your strengths and identify some of the gaps.

For instance, you can say, “I was just interviewing a patient and their family about their recent readmission and here’s what I learned that relates to this work.”

Have multiple conversations. Then along the way you get to the next step, which is really to make the ask. What are you asking for? It’s usually people, time or attention.

Helen Osborne: Money?

Barbara Balik: Money. Those conversations lead up to saying, “If this is our purpose and our why, it links to our strategy this way and we’ve seen these great outcomes and these gaps, what do we do next to make a difference?” That’s when you get to the specifics of “Here’s what we should do.” Have that in your sleeve.

Part of this step that I talk about is making a plan and then an ask. What do you need, when do you need it and in what sequence?

Helen Osborne: For this plan, do you want something big and visionary or do you want something that says, “In the next month, in the next quarter or in the next year, we would like to do this or that?”

Barbara Balik: You’ve hit on all. You want the bigger plan, so the aspiration is we’ll achieve our strategies and our goals by becoming a fully literate healthcare organization. It’s not something you’re going to put on a billboard, but something that shows up every day. Say, “To get us started in the next 90 days, here’s what we need to do.”

Helen Osborne: Your recommendation is being specific even in this plan. You don’t want to just say, “Can we just do something?” You want to say, “This is what we would like to do. This is the big vision we have and this is what we hope to accomplish sooner rather than later.”

Barbara Balik: Exactly. Sometimes people get concerned and think, “I only have this one time to ask for it,” so they’ll say, “I need five FTEs and $500,000 to get going.” That all leads to what I call the ERS, or eye-rolling syndrome. It’s not going to happen.

Helen Osborne: As you just talked about something there, Barbara, you’ve been in those lofty offices. I was not invited in there all that often, even as a Department Manager. It’s very intimidating to do this and you feel like oh my goodness, this is my only chance.

Barbara Balik: Exactly.

Helen Osborne: Is that the way you feel about it as a Senior Leader?

Barbara Balik: What you recognize when you are in a more senior leadership role is that things evolve over time. You know that things take time. Most organizations have a five-year strategic plan, so senior leaders, while needing to be short-term focused, also know that it’s longer term.

My experience, both personally and with colleagues, is that they appreciate somebody who can see the bigger picture and link it to the strategy and someone who says, “Here’s what we need to do in the next 90 days.

Helen Osborne: Again, be specific, and it sounds like do your homework and think about this one.

Barbara Balik: Exactly. It may be as simple to do as saying, “We need some of our communication team time to make sure we screen all our current patient education material so they’re pertinent and useful and aren’t just a source of waste.

“I think we can eliminate 50% of our patient education material by working with our patients and families and doing a literacy screen on them.”

Helen Osborne: Do you know what I just heard when you did that? You had measurable objectives, you were specific, you linked to the bigger vision and you did it specifically. That’s a great example. Thank you.

Barbara Balik: The more specific you can be, the better. You don’t get into the weeds and spend hours there, but give a few concrete examples. Also, recognize that health literacy isn’t just about patients, families and community members, but also our employees.

One of the things that the Environmental Services Director, when I was CEO of a hospital and clinics, helped me to realize was the percentage of employees in environmental services who had English as a second language and the complex work they had to do to understand the instructions for cleaning rooms appropriately.

That’s linked to infection prevention. Centralized sterilizing is about the effectiveness of your operating room suite.

Helen Osborne: Again, it’s making it all really concrete and addressing issues that are a factor today.

Barbara Balik: Exactly. Again, if you have the endorsement and the support, you need to be very specific about what that support looks like. For instance, say, “Jim, our CMO, Chief Medical Officer, is willing to be the champion for this and he’s going to convene a meeting of three or four key directors we think are important to leading this work.” That’s a great statement to make to a senior team or the CEO.

Again, be clear on who you need to get the okay from. You may not need the CEO. If you’ve got the CMO and the CNO or Chief Experience Officer saying, “This is the best thing since sliced bread,” go with it.

Helen Osborne: These tips are great. If we did all this, would it work?

Barbara Balik: I think so. There’s no guarantee. If it was that, I’d be writing a book from a beach. From what I know about how to get things done in an organization, these help.

Then really capture your early stories of success. Make sure that at least 50 people hear about your stories of success and get them to be success-story carriers also.

Helen Osborne: It’s creating a buzz.

Barbara Balik: Exactly.

Helen Osborne: This all sounds like great news. It sounds actionable. It’s a little intimidating, but certainly actionable. Thank you for sharing that with us.

My nagging concern goes back to that bad experience I had many years ago. What do we do about those naysayers and those negative folks?

Barbara Balik: The final point I make is to recognize when the barriers won’t change. The naysayers and the negative folks may be in different roles, so how important are they?

If you have peers who are naysayers, but they’re the kinds of folks who are naysayers about just about everything, just smile, nod and move on. Don’t devote any time.

There’s the adage that says, “If you get those who are protesting on your side, you’ll have great success.” Social science literature says, “No, that’s not accurate.” Go for those who you think are enthusiastic, positive leaders. If they don’t get it now, they’ll get it quickly. There’s where you spend your time and energy.

If you can’t find anyone in the senior team to support you, then you need to pause and say, “What’s going on in the context? Are there just too many distractions that this needs to be put on the back burner for 30 days?” Then you bring it back out again.

Recognize when you’re pushing a rock up a hill that’s just not going to go anywhere. I’ll give you an example of where I was the rock that wasn’t going anywhere.

A wonderful manager that was hired at the organization ran an orthopedic department and had come from employee health. She knew all about employee health and safety.

I was a huge champion and, as the Senior Executive for Patient Safety, was very unknowledgeable about employee safety. It was one of those things that I didn’t know what I didn’t know.

Her name was also Barb and she would come to me and say, “To be consistent, we need to give as much time and attention to employee safety as we do with patient safety.”

I would do the smile and nod and say, “We’ll get to it,” kind of thing. I really wasn’t acting on it. She kept coming back about once a month and she would talk with others and got some support from other people.

She brought statistics forward about the impact of injuries and the stories. She did a lot of what I’m sharing here today.

A lot of the things I share are not because I did them all right, but somebody along the way did them right with me. Eventually, the light bulbs went on for me, but it probably took her the better part of six months.

Helen Osborne: Thank you sharing that story too. It’s not always good news or easy. Barbara, I’ve just learned a lot and I feel so encouraged just listening to you going through this.

You’ve given us so much to learn from. You’re so quotable, repeatable and wise. How can people learn more about the work you’re doing now or learn about how to have these conversations with senior leaders?

Barbara Balik: Thanks, Helen. I really appreciate your feedback. I always value that. On our website, I’ve put a couple of links under resources.

Helen Osborne: Your website is?

Barbara Balik: It’s www.AefinaPartners.com. Under the Resources tab, you’ll find a link to the notes I put together for today’s talk and some other resources that you can use.

Helen Osborne: Thank you. We will also have those links on your Health Literacy Out Loud web page. Barbara, thank you so much for all you’ve done, do, continue doing and for being a guest on Health Literacy Out Loud.

Barbara Balik: Thank you for asking me, Helen.

Helen Osborne: As we just heard from Barbara Balik, it is so important to make a compelling case about health literacy. But doing so isn’t always easy.

For help clearly communicating and advocating about health literacy, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free month e-newsletter, 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, Stitcher Radio and on the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.org.

Did you like this podcast? Did you learn something new? If so, tell your colleagues and tell your friends. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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