Helen Osborne:Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z. I also am the producer and host of this podcast series, Health Literacy Out Loud.

Today, I’m talking with Dr. Audrey Riffenburgh, who has over 20 years of experience in health literacy and plain language. Audrey is the president of Health Literacy Connections that was formerly called Plain Language Works.

Her firm helps healthcare systems, health-related agencies and companies use health literacy and plain language to improve audience communication and meet their organizational goals.

Audrey is widely recognized for her many health literacy accomplishments. This includes being the Senior Health Literacy Specialist at an academic health system, where she helped lead efforts to improve communication and access for patients and families to become a more health literate organization.

Audrey often speaks at conferences and workshops, has co-authored several publications and served on national panels and committees.

She earned her Ph.D. in Health Communication, focusing on the implementation of health literacy initiatives in healthcare organizations.

Audrey and I have known each other as health literacy colleagues and friends for many years. I’m delighted she agreed to be a guest on Health Literacy Out Loud.

Welcome, Audrey.

Dr. Audrey Riffenburgh:Thank you, Helen. It’s great to finally be on this podcast with you.

Helen Osborne:I’m delighted with that, too. You and I have talked about many topics. I’ve even interviewed you for articles years ago, and that was on assessing readability.

I’ve been listening to some of your presentations in different forums and, now that you have your Ph.D., see that you’re focusing more on making a difference at an organizational level.

You raised a topic that I had never quite heard before. I’m intrigued and I think our listeners would want to know more, too. It’s called a health literacy listening tour. Please describe what that is.

Dr. Audrey Riffenburgh:Sure. The term “listening tour” originally started more in corporate America and human resources. People like CEOs that are coming into new positions and doing a top-down listening tour where they go out and just meet with the people they’ll be supervising and the people in their organization to find out others’ perspectives.

Helen Osborne:We need to know that in health literacy. We’re corporate. We’re not just working at the bedside or in the clinic.

Dr. Audrey Riffenburgh:That’s right.

Helen Osborne:We’re part of that picture, right?

Dr. Audrey Riffenburgh:We certainly are, but the way that we’re looking at using the listening tour is not that top-down like the CEO. We wish it would be the CEO asking about health literacy, right? But usually, it’s not.

Usually, it’s somebody that’s maybe mid-range or even at the grassroots level, some of the staff at the lower level that want to know more about what’s happening in their organization and how they can have more of an impact.

They should go out and meet with people and listen themselves to try to learn more about the lay of the land and figure out, “What can I plug in to? What can our program and initiative help with?” instead of creating a freestanding health literacy initiative, which is often what we try to do when we start.

Helen Osborne:I appreciate that focus. Listeners, we’re talking to you, all of you, the same folks who come to conferences.

Somehow, we’ve been bitten by that bug of health literacy, just as I was, just as you were, I’m sure, Audrey, years ago. We somehow want to make a difference beyond our own enthusiasm and passion.

Are you talking to all of us, not just the people at the very top of an organization?

Dr. Audrey Riffenburgh:Absolutely. In fact, I’m probably speaking mostly to the people that are not at the very top. I’ll say they tend to know a whole lot more about the broader scope of what’s happening in the organization.

If you’re down at a manager level or below, like I was when I worked at my hospital . . . I worked for somebody who was an executive director of one of the divisions, but I didn’t really have access to the VPs and the people up at that level.

You may not. If you start a listening tour, you may not have access to that top level, but your job is to try to get up as far as you can and meet with as many people as you can.

Helen Osborne:Tell us what happens. It’s a magical term, and I really like that, but what happens? What does it take to do this?

Dr. Audrey Riffenburgh:There are a lot of logistics in just setting up the meetings, which is so interesting. First, you have to find out who you should be interviewing.

The best way to do that is to sit down with your supervisor and find out what he or she knows about what’s already happening. They may know that there’s a chronic heart failure initiative where health literacy might be able to plug in.

There was one at my hospital. I didn’t know about it the whole time I was there because nobody thought to mention it to me and I didn’t think to ask specifically.

Those are the kinds of things that if they’re happening, you really want to find out. Sometimes, it can be hard to find out.

Start with your supervisor and say, “Who should I talk to?” Of course, get permission, because sometimes in hospitals they’re bureaucratic and you shouldn’t be going up without your supervisor’s permission for sure.

Helen Osborne:They are a bureaucracy, yes.

Dr. Audrey Riffenburgh:Huge bureaucracies often.

Sit down with your supervisor and say, “Where should I start?” Then find out, and maybe she or he knows, but maybe not, who the person is that makes appointments for those folks, and what is their email address? Then you have to email the person who makes appointments and tell them what you’re wanting to meet about, etc.

The sheer logistics of it can be a challenge.

Helen Osborne:How do you explain what this listening tour is, whether to your supervisor or the person you’re trying to make an appointment with? You’re trying to get a half an hour with the vice president of something, a big deal. How do you even frame this?

Dr. Audrey Riffenburgh:Let me just step back to something you just said. A half an hour is the perfect amount of time to ask for. If you ask for more, you’re less likely to get the meeting. It needs to be a really quick, focused meeting.

When you call to make the appointment and when you first go in to talk to somebody, the way to introduce yourself is to say something like, “I want to get the lay of the land,” or, “I want to explore how we can best use health literacy practices to help support our organization’s goals and continue the positive momentum we have going here,” or something like that.

Attach your desire and interest in learning about what goals they’re responsible for or what goals they’re working on or they know need improvement. It’s that kind of thing.

Helen Osborne:Do you have to even start at the beginning, explaining what health literacy is to someone that high up? Are they clueless, really, about what we’re talking about?

Dr. Audrey Riffenburgh:Yes, often, they might be. You do need to be prepared to just give them a really brief little intro to what it is you’re talking about.

If they do know a little about it, what they’ll often be thinking and know about is maybe your efforts if you’ve already started your initiative.

Your efforts often start with revising print materials, so they might be thinking, “It’s that editing thing we do. It’s that plain language thing. It’s that dumbing down thing,” in their head. They might even say that out loud. We hope not.

Helen Osborne:If they’re thinking it, they better say it.

Dr. Audrey Riffenburgh:Right. You do want to make sure you talk about other things, too. Give other examples of how fixing the documents so they’re easy to read in a chronic heart failure program would be helpful, but you can also teach the nurses that do follow-up phone calls with people when they’ve returned home how to do teach-back or something like that.

Give really specific examples so they can begin to think of it more broadly than just the documents.

Helen Osborne:It sounds like you have to frame whatever they know or believe about health literacy. If you only have a half an hour, which can fly by, it sounds like you have to do that pretty efficiently because that’s not really the full purpose of this listening tour. The word listening is not about talking. It’s about listening.

Dr. Audrey Riffenburgh:Exactly.

That’s really something to keep in mind. It’s not about talking about what you can do for them or what ideas you have for them. It’s just getting in, giving them the frame and then beginning to ask your questions, like, “What are the goals of your area? What are the strengths in this area that you oversee, and what are the things that could be changed or need work?”

Then think about or even ask, “Are there things that communication could be improved where we could help with that?” Basically, just ask some questions and then let them talk.

It might be good to start with, “Are you familiar with health literacy and plain language or our work, or would you like me to give you a quick recap or summary of what we do?” That’s a face-saving way. They might say, “Yes, I’m familiar with it, but go ahead and tell me.”

Helen Osborne:How do you frame this? I can just see someone saying, “Okay. Why don’t you go do that?” How do you frame this into a bigger issue than just one project you’re talking about?

You don’t need to take up their time just to have the okay to do one project or one booklet. How do you let them know that you have a bigger vision than that?

Dr. Audrey Riffenburgh:When you talk about getting the lay of the land or exploring the best way to use health literacy practices to support organizational goals, you’re really talking about that you’re gathering information and data so you can go back and do some thinking, planning and long-range strategic planning on the areas that health literacy or plain language could be best used.

Really, what you’re looking for is not just where it could be most useful, but you’re also really looking for “Where can I measure any kind of improvement? Where can we get data?”

You can find what I call the low-hanging fruit, the projects that would be easy and quick to do, small in scope and you could do a before-and-after evaluation of the data.

Here’s another example. Often, hospitals have a real struggle getting people to show up for their colonoscopies in the first place at all, but then when they do show up, getting them to show up, what they call, “clean,” having done the prep properly and not showing up saying, “I didn’t realize I wasn’t supposed to eat red Jell-O,” which is a no-no.

You could ask that department and go to them, or maybe it will come up when you meet with somebody who’s in charge of that department, and they could say, “We have a really hard time with that.”

This might even be good just to give an example when you’re first meeting. For example, somebody who’s over in the GI department might say, “We really struggle with getting people to show up clean for their colonoscopies.” That’s another really concrete example.

If you could get that department to cooperate with you on a little project and they could say, “Let’s see what our rate of no-show is and then our rate of showing up but not clean,” then you do the little intervention where you revise the instructions.

Maybe you add in a phone call where the person who’s making the phone calls before the procedure is trained in doing teach-back.

Then you measure the data after that and see what improvement there was. Hopefully, there will be a big improvement.

Helen Osborne:I’m really getting the sense that you’re introducing yourself to someone you wouldn’t normally have conversation or relationship with.

Dr. Audrey Riffenburgh:For sure.

Helen Osborne:You’re clarifying what health literacy is and isn’t, and where it might go. Then you want to hear more about where the institution or organization wants to go and how you can be a part of it.

As you’re talking about this, I know from my hospital days quite a while ago, I wanted to be more than known as a project person. I had a bigger version for where health literacy would go. I believe that you and I shared that. We’ve talked about that a lot.

Some of our listeners might be very happy with the okay to do projects, before and after, and go that incremental change. If you have a vision like you and I had, that bigger change vision, how do you keep that tone of it in this half hour?

Dr. Audrey Riffenburgh:Gosh, that’s a good question. The first thing you need to make a broader change is you have to make the case for health literacy. People aren’t going to go for a broader change unless they understand what it is, how it’s powerful and why it’s useful.

The best way to really get that is to get some local data. You can also show them the data on literacy and health literacy in your area by using the Health Literacy Data Map. If they just Google “Health Literacy Data Map,” that will come up.

Helen Osborne:That’s a great resource. We’ll have that on your Health Literacy Out Loudweb page.

Dr. Audrey Riffenburgh:Then give the overall statistics for the nation and all the things we typically show, like it’s linked to health outcomes and those kinds of things.

If you don’t have local data, it’s much harder to sell it, so I look at that project and any projects you do as the first steps in gaining the data or ammunition that you need to then go back and say, “We’ve done this. Now we’d like to do this, this or this.” Then you can begin to really expand it.

Helen Osborne:It sounds like you go into this being very prepared. You don’t need to show that you’re that prepared, but you’re ready to address this for whatever direction that person has an interest.

Dr. Audrey Riffenburgh:Right.

Helen Osborne:Have you seen anything that specifically works or even doesn’t work on these listening tours?

Dr. Audrey Riffenburgh:Let me go back to what you said about talking to the person and what they’re going to say.

I just want to clarify that they will often not have any idea how health literacy is going to help, so they’re probably not going to be asking you for a project. They’re probably not going to say, “Can you do this?” They’ll just tell you what they do and what their challenges are.

Then at that point, you don’t want to make any promises. You don’t want to say, “We can help you with this.” You can say, “This is really helpful.”

Maybe if you have some ideas, you can say, “I have some ideas,” or you can say, “I don’t have any ideas exactly on this yet, but I’m going to think about this and talk with my colleagues or my supervisor,” or whoever, “and think about it. I’m going to let you know what we come up with. Then I’ll come back and tell you what my proposal is or what my ideas are.”

Helen Osborne:I really like that. You’re not promising, but you’re leaving it in a way that this is the beginning of an ongoing partnership.

Dr. Audrey Riffenburgh:Exactly. Then just make sure they have your contact information and so forth.

In that 30 minutes, you’re gathering information, but there are a lot of other things that we hope will happen.

You’re building goodwill. You’re raising awareness of the fact that you and your program are even there. Goodwill, because if you listen, people will like that. Your passion and interest in health literacy will come out. Maybe they’ll even say, “How did you get into this?”

If people decide that you’re credible and trustworthy, then they’re much more likely to tell other people through those internal, interpersonal communication networks that we know operate.

They’re more likely to tell other people, “I met with her for 30 minutes and she was pretty cool. She said she’s going to come back to me with some ideas.”

That’s neat, that kind of thing where you are creating an impression and giving them an opportunity to think about what you discussed, too.

Then just invite them. Say, “If you come up with any ideas, let us know, too.”

Helen Osborne:I love that. Even if you just see each other in the hallway or cafeteria, you probably are more likely to say hi than you would at another time.

I wish I knew this back in my hospital days. I newly had heard about health literacy, passionate about it, positioned to make some level of difference, not a big one, but I didn’t know about the tools of organizational change and it was a rocky path.

Dr. Audrey Riffenburgh:It often is.

Helen Osborne:I’m so delighted that you’re looking at that big picture and helping us organizationally in that way.

Dr. Audrey Riffenburgh:Let me share a quote about somebody who did this at this stage in her organization, kind of at the beginning where she was meeting with people.

This came from my dissertation research. I have permission to use her quote, but we’re not using her real name. I’m calling her Sheila. She works in a single hospital that serves patients from several states.

Then I have a quote from somebody who works in a different kind of system.

She says, “I scheduled meetings with all the key leaders. That’s when I was starting to understand the culture of the organization, where the strengths were and where the opportunities were for my program. Because I was new to the organization, it ended up being really a crucial piece of getting off on the right foot.”

That was her getting to know other people and other people getting to know her.

I love that she says “understand the culture of the organization,” because that’s also an unspoken, implicit piece that comes from dealing with people at these different levels. You learn a lot more about the culture.

Also, you get to see who pooh-poohs you and scoots you out the door, and who says, “I’m so glad you’re here. I’ve heard about this health literacy thing, but I really don’t know much about it.”

You might be able to recruit some of them or get them to suggest people that could serve on some of your committees or task forces or something like that.

You can find out who your allies are and then find out who you need to work on to turn them into an ally.

Helen Osborne:This is wonderful. I’m so glad you’re sharing this with the listeners and at the conferences, and that you focused on this in your research.

We can’t cover it all. We only have a half an hour or less.

Also, I want to say I don’t think this is just hospital-based work.

Dr. Audrey Riffenburgh:Correct.

Helen Osborne:This could be done in a clinic, public health or other ways, too. I think just the sheer fact of listening, opening yourself up to meeting other people, sharing the message and listening to their views is important.

Dr. Audrey Riffenburgh:That’s right.

Helen Osborne:What are ways that our listeners to Health Literacy Out Loudcan learn more about making an organizational difference?

Dr. Audrey Riffenburgh:There’s a guidebook that I’m actually a co-author of but Dr. Mary Ann Abrams is the primary author. She’s a physician who was in charge of quality improvement in her system, Iowa Health System. She’s now moved on somewhere else. The guidebook and her knowledge and information in that are just exquisite.

I’m looking for it. What’s it actually called?

Helen Osborne:I have it right here. I’m ready for you. Organizational Change to Improve Health Literacy. We’ll have it on your Health Literacy Out Loudwebsite.

Dr. Audrey Riffenburgh:You can download the PDF for free. It’s a really excellent guidebook.

We’re going to be doing a new version pretty soon, but that one is really terrific, and the chapter on engaging leadership, in particular. If you get it and that’s all you read, I would really recommend that you get it for that, if nothing else.

Helen Osborne:What about if someone would like to develop a relationship and learn from you, Audrey? Not just reading a book, but having it a little bit more personalized.

Dr. Audrey Riffenburgh:That would be wonderful, too. The listening tour is part of a coaching program that I offer. I do offer online consulting, coaching and training.

The online part is what’s different and new that I’m doing. That is where people don’t have to travel to a conference and they can still get the kind of consulting and coaching that’s very helpful and continuous learning. I do that specifically on organizational change and then also on developing easy-to-read materials.

Helen Osborne:Great. How do they reach you?

Dr. Audrey Riffenburgh:They can go to my website at www.HealthLiteracyConnections.com, or they can write me at ar@healthliteracyconnections.com.

Helen Osborne:Perfect. Audrey, I am so glad I finally got you to be a guest on Health Literacy Out Loud.

Dr. Audrey Riffenburgh:Me, too.

Helen Osborne:Sharing this information is just a wonderful way to frame someone’s immediate interests and passion with a whole bigger picture of making a long-term difference.

Thank you for all you do and for sharing it on Health Literacy Out Loud.

Dr. Audrey Riffenburgh:Thank you, Helen, for doing Health Literacy Out Loud. It’s been a huge contribution to the field.

Helen Osborne:As we just heard from Dr. Audrey Riffenburgh, it’s important to look at the big picture of health literacy along with the day-to-day work we have to do.

But doing do isn’t always easy. For help clearly communicating your health message, please look at my book, Health Literacy from A to Z.

You might especially be interested in Chapters 4 and 27 that have much more information about the business side of health literacy and organizational efforts locally, regionally and nationwide.

You can also contact me directly at helen@healthliteracy.com.

New Health Literacy Out Loudpodcasts come out every few weeks. You can get all episodes automatically by subscribing for free at www.HealthLiteracyOutLoud.com. You can also find us on iTunes, Google Play, Stitcher Radio or wherever you get your podcasts.

Please help spread the word about health literacy and Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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