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 pretty amazing people.

Today, I’m talking with three folks, Mary Ann Abrams, Cyndy Hall and Shelby Chapman, all leaders who are thinking and acting big about health literacy. Here are just a few of the many high points about who they are and what they do.

Dr. Mary Ann Abrams is Clinical Assistant Professor in the Department of Pediatrics at Nationwide Children’s Hospital, The Ohio State University College of Medicine.

She previously led Iowa Health System’s Health Literacy Quality Initiatives and Development of Health Literacy Iowa. Mary Ann is also author of Building Health Literate Organizations: A Guide to Achieving Organizational Change.

Cyndi Hall works at the Carolinas Healthcare System rolling out health literacy education to more than 500 medical offices. As Project Manager for Carolinas Teach Well Educational Program, Cyndi inspires teammates to use proven health literacy techniques and best practices.

Shelby Chapman is Health Literacy Program Manager at Children’s Hospital Colorado. This program encompasses patient and family education for the whole system, effecting change throughout the organization.

I’ve met and worked with each of these women and have so much respect for their accomplishments. However, when I heard them speaking together on a panel at the Institute for Healthcare Advancement’s 2016 Health Literacy Conference, I was even more impressed.

Individually and collectively, Mary Ann, Cyndi and Shelby are doing what I dreamed about and wished for when, more than 20 years ago, I got involved with health literacy.

Welcome, everyone, to Health Literacy Out Loud.

Mary Ann Abrams: Hi, Helen.

Helen Osborne: I just want to let listeners know we are doing this by conference call and we will try to identify each person by name until you get familiar with their voices. It’s a challenge for all of us, but I really wanted you to hear them talk about thinking big together.

Taking it from the top, I welcome hearing from each of you. Thinking big about health literacy, what does that mean to you?

Cyndi Hall: This is Cyndi from Carolinas Healthcare System. When I think about thinking big, I want to go beyond just the education of our employees and teammates and really get across the entire culture of our organization.

We have a very large organization, so that means getting support at the board level, at the physician level, with our teammates and with all of our leadership.

I think that, in order to make things work, you really need to have a cross-functional group, not only in disciplines, but also in levels of the organization.

Thinking big to me means being really inclusive and inviting for the entire organization to work on health literate organizations together.

Helen Osborne: That’s neat for me to hear, Cyndi, because it’s not just the folks doing the communication directly with patients and families, but also those who make all that happen and possible. I really respect that big vision and inclusiveness with leadership.

How about you, Shelby?

Shelby Chapman: For me, thinking big is really about how we change the entire system to meet the needs of our patients and families.

When I think of my previous experience where I worked with refugees and I tried to help them navigate our health system and, on a daily basis, observed how challenging our healthcare system is for people to navigate, this opportunity at Children’s Hospital was an opportunity to say, “We don’t have to accept a system that doesn’t meet people’s needs or that’s difficult to navigate or understand.”

Thinking big to me means changing the organization, similarly to what Cyndi mentioned, at all levels. How do we think about meeting people’s needs, meeting them where they’re at and increasing the ease of the system on that consumer end?

Helen Osborne: That’s really interesting that both of you are working in healthcare systems and you’re talking about changing the whole system. It’s just much more than coming up with a simpler word here or there or a handout that’s done clearly, which is important too.

Mary Ann, you’ve worked in big systems in a big way and you’re also a physician. What does thinking big mean to you?

Mary Ann Abrams: I would second everything that Cyndi and Shelby have said. I would also add to that how important it is to look down the road and really think about how, once you’ve made all these excellent changes, to embed and hardwire those so that they become part of the culture and standard operating procedures and the way people just routinely think.

It’s sustaining that and also how important it is to really include the voice of the patient, family and caregiver to really round out that perspective as you seek to make change.

Helen Osborne: Thanks for that. I want to get onto both of those principles too, about how you embed this in the culture so it’s sustainable. It’s not just saying that you are in your present positions and you’re great and passionate about it. But how does this go on in the future?

Let’s bring it back to the people we care about most, the patients and their families. Talk about that more from the very personal part to the great big system part. How do you bring in patients, families, communities and learners?

Mary Ann Abrams: We had a wonderful opportunity to partner with patients’ families and adult learners, those who are learning to read as adults, in our work in Iowa.

We were fortunate to be able to have the adult learners as active members of our health literacy teams and they also participated on some of our other quality and safety committees.

What they brought was that unique perspective of what they need to know and what they don’t necessarily understand. They opened our eyes and gave us wonderful tips and advice, and they also shared their stories. Sharing those compelling stories is another way to move this work forward.

Helen Osborne: Is that what inspired all of this to happen? I know, Mary Ann, that you’ve been doing this a long time. Was working in that what inspired all your efforts to then do such big changes?

Mary Ann Abrams: I think that’s true. We were fortunate to work with some real adult-learner leaders in health literacy, one of whom many of you will probably know, Archie Willard.

Helen Osborne: I have a podcast with him. I’ll do a link on our Health Literacy Out Loud page.

Mary Ann Abrams: He’s wonderful. He and his colleagues, Norma Kenoyer and others, are wonderful spokespeople. Their ability and willingness to share their insights motivated so much work and inspired people. I think that is a key, but that doesn’t mean that everyone has to go to Iowa.

You reach out, you find partnerships in your own community, and you find patients and families who are involved in the care in your healthcare setting who might be willing to share their stories, even if it’s in a smaller, more quiet way.

Helen Osborne: It’s just capturing the human part about why we are doing. I would imagine each of us has our own stories. I know, I have mine from my hospital days as well.

Why is it so important now? Health literacy wasn’t a term widely used 25 years ago, but now it’s all the buzz. Why now?

Cyndi Hall: I think that one of the reasons that it’s really important and one of the things I like to impart on my teammates is that it really affects all the things that we’re measuring at federal and state levels and all of our quality metrics.

Readmission is a really big issue, and I know Shelby can talk about the work they’ve been doing there. Someone is much more likely to get readmitted to the hospital if they didn’t understand their instructions upon discharge.

Even infection control, getting sepsis, all the things that we are working on as a healthcare community are really affected by health literacy.

One of the things that we do at our organization is we try to have a connect-to-purpose for everything that we do.

Whenever I talk about health literacy, I talk about readmission, sepsis, and medication errors. All of those things really tie back to the patient understanding that which we tell them.

Helen Osborne: That’s how you talked in the beginning about what you’re doing at Carolinas. You’re working also with senior leadership, and senior leadership very much would care about things like readmission, infections and all those metrics we need to know.

Cyndi Hall: The patients also really care. They don’t want to be readmitted and they certainly don’t want to get an infection, so it’s a win-win on both sides.

Helen Osborne: They sure don’t. Mary Ann, I know you’ve done work, especially in your guidebook, talking about this “Why now?” in health systems and organizations. Can you just talk about that a little bit and how that came about?

Mary Ann Abrams: There are a couple pieces to that. One is that we have data that show the health system we have is very difficult for 90% of people to use.

It’s not deliberate, but the system has evolved to where almost 90% of people struggle with understanding, accessing, and using information to take care of themselves and their families.

We’ve shifted from focus on just individuals to looking at health literacy at the system level. So when we talk about addressing health literacy, it means improving the skills of the system and not just individual people.

A lot of that work, I think, is evolving from the recent report from members of The Institute of Medicine’s Round Table on Health Literacy on “The 10 Attributes of a Health Literate Healthcare Organizations.”

Helen Osborne: Those are key. We have another podcast on that. It’s key principles about health-literate healthcare organizations. To me, as someone who’s been doing this work awhile, as all of you have been, I saw that almost as a game changer when we went from the individual to the systems.

Shelby, what tips do you want to start adding? What have you learned? What have you done that you’d like others to really know about that maybe they can start putting in place where they are?

Shelby Chapman: Some of the things that I’ve done as I’ve been growing the program here at Children’s Hospital Colorado is really to have an interdisciplinary focus.

I know that Cyndi has mentioned this as well, but it’s really important that health literacy not be seen as just a nursing function. That it’s seen across the organization that this is really interdisciplinary and it’s about everyone that interacts with our patients and families.

I think, to get the buy-in that you need across a large organization, you really have to go about making the case for health literacy in as many areas as you can. Sometimes that means focusing on different things.

When you’re talking about patient safety, we’re talking about how this can help our safety outcomes for the hospital. There’s a role for health literacy in that work. There’s also a role for it in reducing our readmissions.

You have to think about your audience, tailor your message, and help them see the connection between health literacy and achieving those outcomes that the hospital and the patients and families are really interested in seeing.

Helen Osborne: That works not just at a senior level, but at the practice level also?

Shelby Chapman: Absolutely. I think it’s at all levels. It’s really important that, when you’re instituting new changes, you’re including all of those audiences from the start.

If you’re going to institute a change within a clinic, you need to have the buy-in and include folks that are doing the work at the front lines from the very beginning if you’re going to be successful with any kind of change that you’re trying to make.

Helen Osborne: Thanks for that. How about if we hear from Cyndi too, with some kind of a tip–something that you found that really worked, something you haven’t already said, or we haven’t heard?

Cyndi Hall: I think one of the things we have found that has been very successful is working, like Shelby said, with other disciplines. Patient safety often will send me something saying, “Hey, we just got this story about something that happened. Can you use it?” I say, “Yes. That’s a perfect example of health literacy.”

Beyond that, it’s working with the physicians and making sure they’re on board.

I think I told you the story about how when we first started rolling this out we used “Ask Me 3” from the National Patient Safety Foundation.

One practice implemented it one day, and by lunchtime the doctor came running into the break room asking, “Why are all my patients asking me these questions?” He had not been educated ahead of time. Maybe he missed that staff training.

One of things is, when you do something big, you really need to make sure everybody is ready to go. You implement things slowly and you use scientific techniques to implement them, like small tests of change. While you think big, you have to start small and then grow effectively and thoughtfully.

Helen Osborne: Great. Thanks. How about Mary Ann? What’s a new strategy that really has worked for you in your experience?

Mary Ann Abrams: I have to take what Cyndi said as well as Shelby just a little bit further. One thing I think that’s important is when you have your multidisciplinary team and you have your change package put together, don’t be afraid to get started.

Don’t let the perfect be the enemy of the good. Use the small test of change and try things that might be a little bit new, different, or uncomfortable with one patient, one time.

Help people work out the bugs, get comfortable, start ramping up and then they become health literacy champions. They share these successes with their colleagues, their insights, their aha moments, and then that’s another strategy to help spread.

Helen Osborne: Great. Thanks, everyone.

I’m going to ask you a hard question now. Get ready for this one. You are all accomplishing wonderful things. It just sounds like this was an easy, smooth pass. Someone just laughed in the background. I’m thinking there might have been some bumps along the way.

Would you be willing to share with listeners something that didn’t work as well and perhaps how you overcame that hurdle?

Cyndi Hall: I’d be happy to answer that because it was me chuckling. The story that I told at the IHA conference is that we’ve been doing health literacy for a long time, and when we initially dipped our foot in the water in 2008, we basically did what most people do, a very traditional rollout of education.

In 2012, we decided to assess how that worked, and it turned out that it didn’t work very well. While everyone has been educated, they really weren’t using the techniques and the tools. It hadn’t become hardwired. It wasn’t being sustained.

We put our team on that and we really thought about it. I think what we learned from that, because we’re in a successful rollout right now, is that it’s not enough just to educate. You have to do some sustaining and hardwiring afterward.

We do observations now and we have them reported. It’s a year-long period. That sounds like a lot, but we have found that if we don’t get these observations and we don’t hardwire the process, the tools go away.

Helen Osborne: Thanks for that. That gets back to what Mary Ann talked about in the beginning about the sustaining, so we’re going in that direction because that’s what’s needed.

Shelby, how about a little candor here? It looks so easy. Was it?

Shelby Chapman: No, it’s never easy. There are definitely those days where you’re thinking, “Oh my gosh, this is so much more difficult than I anticipated.”

For example, in 2015, we rolled out teachback training to nearly 3,000 of our employees, which in terms of getting the education out there was very successful.

The part we have been struggling with is having the documentation to show that they’re actually using the teachback method within our medical record system.

When I go out and talk to team members and I do observations, people say, “Will you please stop talking about teachback? We know what it is and we’re using it,” which is great. That’s what you want to hear.

However, when we look at the metrics, which organizations depend upon because you need not just people to say that they’re doing it, but you have to have the metrics to prove it, our documentation of use of the teachback method continues to be much lower than we would like. You have to come up with different strategies.

Going back to that idea of sustainability, one of the things that we’re going to be rolling out later this year is what we’re calling our Health Literacy Liaison Program. We’re going to have an opportunity for people that are providing direct services and who are at the bedside to get together once a month for continuing education and then to really be responsible for being the unit champion for these initiatives.

They’ll be responsible for doing those audits and helping people figure out how to do the documentation on each unit within the organization so that hopefully we’ll start to see those things improve.

Helen Osborne: Wow.

Cyndi Hall: I would add to Shelby’s thought that we do the observations and that works really well. We’ve been doing that successfully now for about two years, but I will tell you our documentation in the electronic health record is still lower than what we see with our observations.

I think that’s somewhat because of the software. It’s so many clicks in and you have to get to the right screen. I don’t know that we’ll ever see the chart necessarily reflect what’s happening in the practice.

That would be ideal, but we’re trying to find other ways to look at it, like the Communication Bundle with Press Ganey. We’re trying to find different ways to capture metrics other than the electronic health record.

Helen Osborne: This is neat hearing from you. I’m also hearing a theme. Mary Ann, you’re the first one in this podcast to talk about that issue of embedding it in the system and sustaining it. It’s interesting that both Shelby and Cyndi were talking about that being their hurdle now and their hurdle ahead.

Mary Ann, I throw this out to you as we’re concluding this podcast. What are your words of wisdom about sustaining this. How can others go forward with this?

Mary Ann Abrams: I’m so impressed with the work that Cyndi and Shelby are doing and I can’t wait to follow that further down the road together.

In listening just to this last discussion, I would suggest that people be resilient and be ready, because they’re going to encounter another “R,” resistance. Don’t let that deter you or get you down.

Focus your energy on the early adopters. There are always people that will be more interested and less interested.

I think, historically, sometimes we focus on persuading those who are more skeptical, but I would counter to invest in those people who are willing to try, the early adopters, and even think about some sort of behavior motivational interviewing type thing. “What makes you say that?” or “What could we do to maybe make that work more easily for you?”

We know we’ll get challenges about how much time it takes, so think in terms of tradeoffs. “What could we take away to help you be able to use teachback?”

Then don’t forget to close that loop by looking at policies, procedures, competencies and things that help support that sustaining and hardwiring.

Helen Osborne: Wow. This is wonderful. I’ve just learned so much hearing from all of you. I’m sure that there are other listeners and other people doing great health literacy work on a big scale in other places in the US and worldwide. Thank you for sharing what you are doing. You’re wonderful examples and inspiration for us all.

For those who want to learn more, I know Mary Ann put together a guidebook on some of this, didn’t you?

Mary Ann Abrams: Yes, we did. It’s called Building Health Literate Healthcare Organizations: A Guidebook for Organizational Change and it is available on the web at www.HealthLiterateOrganization.org.

It’s an easy-to-read guidebook to help people get started or develop their work further in addressing multiple aspects of health literacy in their organization.

Helen Osborne: I want to thank you all. We are going to have links to the resources that we mentioned in this podcast plus more, on your Health Literacy Out Loud web page.

I so much want to thank you for not only doing what you do, but also for talking with all of us about how you are acting big and thinking big about what’s next, and how to sustain it.

Thanks so much for being guests on Health Literacy Out Loud.

Cyndi Hall: We enjoyed being here, Helen. Thank you for including us. It was a lot of fun.

Mary Ann Abrams: Thank you.

Helen Osborne: As we just heard from Mary Ann Abrams, Cyndi Hall and Shelby Chapman, it is important to think big, act big and do big about health literacy. But it’s not always easy to do.

For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com.

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Until next time, I’m Helen Osborne.

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