Advancing Organizational Health Literacy in Health Care Organizations Serving High-Needs Populations: A Case Study

Abstract

Health care organizations, well positioned to address health literacy, are beginning to shift their systems and policies to support health literacy efforts. Organizations can identify barriers, emphasize and leverage their strengths, and initiate activities that promote health literacy–related practices. The current project employed an open-ended approach to conduct a needs assessment of rural federally qualified health center clinics. Using customized assessment tools, the collaborators were then able to determine priorities for changing organizational structures and policies in order to support continued health literacy efforts. Six domains of organizational health literacy were measured with three methods: environmental assessments, patient interviews, and key informant interviews with staff and providers. Subsequent strategic planning was conducted by collaborators from the academic and clinic teams and resulted in a focused, context-appropriate action plan. The needs assessment revealed several gaps in organizational health literacy practices, such as low awareness of health literacy within the organization and variation in perceived values of protocols, interstaff communication, and patient communication. Facilitators included high employee morale and patient satisfaction. The resulting targeted action plan considered the organization's culture as revealed in the interviews, informing a collaborative process well suited to improving organizational structures and systems to support health literacy best practices. The customized needs assessment contributed to an ongoing collaborative process to implement organizational changes that aided in addressing health literacy needs.

Low health literacy is associated with poor individual health outcomes, inefficiencies in health care services, and increased health care costs. Recognizing that 90 million American adults have difficulty understanding and acting upon health information, and 40 million adults are unable to read any complex text at all (Nielsen-Bohlman, Panzer, & Kindig, 2004) several prominent public health agencies have called for a prioritization of health literacy practice and research (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2010).

Among several suggested research agendas is a call to further investigate the context of health care delivery and the relationship of contextual factors to an organization's health literacy practices. It is notable that the field of health literacy now recognizes a convergence of factors in which the expectations, preferences and skill of the individuals must agree with the expectations, preferences, and skills of those providing information and services and the setting in which those services are provided (Wynia & Jager, 2010). The Institute of Medicine highlights that addressing health literacy is a responsibility shared by those who interact within a health system and external factors such as educational systems (Nielsen-Bohlman et al., 2004).

Health literacy improvements made within an organization, in addition to those directed toward the individual, can lead to better access for patients, an increased quality of care for patients and lower overall health care cost (Koh et al., 2012). To implement these organizational improvements it is important that health literacy efforts are part of a health care center's overall quality improvement plan, are supported by health center leadership, emphasize the importance of both written and oral communication and fully prepare staff and providers to work with the populations served (Brach et al., 2012). There are several contemporary frameworks to guide this conceptualization of health literacy, including the 2004 report from the Institute of Medicine (Nielsen-Bohlman et al., 2004), which features the health system and the health context as a central influence on an individual's ability to understand and use health information.

This shift toward contextual factors is fitting, particularly given that many barriers for health literacy can be attributed to organizational policies. For example, although many care providers are aware of health literacy techniques and may receive continuing education about such practices, many of these professionals report not using such strategies in their routine clinical practice (Turner et al., 2009). Thus, patients’ needs may be better met if health care organizations offer environments that support health literacy best practices, including those offered by health care providers. It therefore has become important to assess the capacity of organizations to provide this support and to use those assessments to inform strategic planning for organizational change.

Several resources have been developed to bolster organizational approaches to health literacy. The Joint Commission has developed a set of organizational health literacy recommendations, including making effective communications an organizational priority, addressing patients’ needs across the continuum of care, and the pursuit of policy changes to address health literacy gaps. The Joint Commission (2007) explicitly links health literacy practices to priority clinical outcomes, including patient safety and quality of care. An assessment manual by Rudd and Anderson, The Health Literacy Environment of Hospitals and Health Centers, provides a toolkit for assessing organizational health literacy-related barriers to health care access and navigation and has been previously used in 10 large hospitals in Spain (Groene & Rudd, 2011). The results of this assessment provide hospital or health center workers insight into their health literacy environment, as well as provide opportunities to eliminate literacy barriers and enhance health literacy. Constructs of this assessment instrument include navigation, print communication, oral exchange, technology, and policies and protocols (Rudd & Anderson, 2006). A second toolkit from the Agency for Healthcare Research and Quality, the Health Literacy Universal Precautions Toolkit, is a comprehensive document that provides several assessment instruments, as well as methods for addressing identified gaps in health literacy practices. Created to be self-administered in a primary care practice setting, it includes questions assessing the domains of spoken communication, written communication, self-management and empowerment, and supportive systems (DeWalt et al., 2010).

Several other assessments have been developed for use in specific settings. For example, Gazmararian and colleagues (2010) developed a health literacy assessment tool specific for health insurance plans, which is accompanied by guidelines and protocols for improving health literacy practices in the context of health plans. Constructs include print information, web navigation, member services/verbal communication, forms, nurse call line, and case/disease management (Gazmararian, Beditz, Pisano, & Carreon, 2010).

In response to the need for organizational assessment and resulting change at the organizational level, the current project adapted existing health literacy assessments to create customized, open-ended instruments to measure health literacy policies and practices in a rural federally qualified health center operating three clinic locations. The overall goals of the project were to prepare a health literacy policy action plan with special attention to organizational factors and to then implement and evaluate that policy action plan. The first step in this process was to carry out a needs assessment in all three clinic locations in order to identify strengths and weaknesses in existing health-literacy related practices, as well as the organizational factors that would facilitate and impede efforts to enhance such practices and the policies that support them. This case study article provides the findings from the initial organizational health literacy needs assessment using three data collection approaches and describes the strategic planning process that was informed by the needs assessment findings. The project extends previous work by customizing collaborative needs assessment instruments, applying these tools to illuminate barriers and facilitators of the medical system, and offering insights garnered from a clinic serving a high-needs population.

Method

This project represents a partnership between an academic research team and the administrative and medical staff of three clinics of a federally qualified health center in rural Missouri. The population living in the clinic communities on average have higher rates of chronic diseases, preterm and low birth-weight babies, those living below the poverty line, and uninsured residents, compared to the rest of the State.

To customize the needs assessment instruments for the project setting and purposes, three existing organizational health literacy resources were considered: Rudd and Anderson, the Joint Commission, and initial work performed at the University of North Carolina for the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit (DeWalt, 2010). Using the major domains of Rudd and Anderson as the organizing framework, relevant recommendations from the Joint Commission and the Agency for Healthcare Research and Quality toolkit were identified. Six established domains of organizational health literacy were included in the adapted instruments: patient–provider interaction, patient education, print materials, technology, inter-staff interaction and policy. The selection of these domains were determined by domains used in other instruments, previous knowledge among the researchers of the setting to be assessed, and background research on the importance of each of these domains. The six domains provided a structure to then guide the process of including customized questions and individual measures of health literacy.

Because this project was a partnership between an academic setting and a community medical center, it was important that the instruments be suitable for collaborative open-ended discussion. The measures for Rudd and Anderson and the Agency for Healthcare Research and Quality were highly quantitative, so we translated these concepts into open-ended questions and observational protocols (Rudd & Anderson, 2006). The result of this process was the development of three customized instruments: (a) an observational assessment; (b) key informant interview guides for all clinic staff types, including administrators, providers, and support staff; and (c) a key informant interview guide for patients (see Table 1). The observational assessment included environmental indicators of health literacy practices and definitions of those indicators according to each domain. The presence or extent of health literacy practices were captured using response categories of yes/no and “This is something that is not done,” “This is done, but needs some improvements,” and “This is done well.” Patient and clinic staff interview guides contained approximately 20 open-ended questions and additional probes, also organized according to domain.

Table 1. Sample indicators and measures used to assess domains of organizational health literacy with key informant interviews, patient interviews and clinic observations

Domains	Key informant interviews—staff ^a	Patient interviews	Clinic observations
Big picture	How are health literacy practices influenced by the health center's policies, systems, and procedures?	N/A	N/A
Navigation and the telephone system	When a phone call is answered (either by a person or an automated phone system), is there an option to hear information in a language other than English?	What would make it easier to find the health center?	A sign indicates a welcome, sign-in, or information desk.
Staff assistance	How do you recognize patients who may have a hard time understanding the health information they receive at the health center?	Was there anyone available to greet you when you first walked into the clinic?	There are enough staff to address and/or welcome all visitors.
Oral communication	How do staff and providers include patients in making medical and health related decisions?	How do you feel about the level of information you received from clinic staff and providers?	Staff uses sentences that are short, direct, and use plain everyday words.
Print materials	What types of educational print materials are available for patients?	What additional information would you like to have to take home with you?	There are a variety of materials available in public areas for patients to take home.
Inter-staff communication	Is there a standard procedure for patient hand-offs that include the sharing of health literacy related information among providers?	N/A	N/A
Technology	How often is the health center's website updated?	How helpful did you find the website?	Televisions are equipped for DVR or VCR use.

The observational assessment was conducted by three members of the academic team (including S.Z. and K.J.) at each of the three clinics within the system. Using the customized observational assessment, both team members completed the assessment at same time. A protocol for using the instrument was also developed to ensure consistent timing for the team members in observing clinic operations. The researchers individually documented their findings and upon completion of the observational assessment, they discussed their findings to reach consensus. Patient interviews were also conducted at each of the three health centers. Participants were recruited in the clinic waiting areas while waiting to be called back by the clinical support staff for their appointments or after they had completed their appointment. If patients were still waiting to see their providers they were asked to complete the interview once their appointment was over and were reminded by the clinic staff. Patients were offered gift cards to a local retailer as incentives for participation. Clinic staff interviews were conducted at all locations as well and were conducted during times that were convenient for the staff.

After each of the patient and clinic staff key informant interviews, the researchers completed topline reports, containing information from the interviews that the researchers perceived to be the main points of the interview. The interviews were also transcribed. Two researchers were assigned to each of the different interview types (patient, administrator, provider, and clinical support staff and nonclinical support staff) for analysis. Researchers reviewed their assigned transcripts, interview notes, and topline reports individually, and then met to reach a consensus on the main findings for each interview type in each of the domains. Once all interview types had been analyzed, a subset of researchers compared domains across interview type of similarities and difference. Findings from all participants and environmental assessments were triangulated to corroborate thematic findings organized in terms of facilitators and barriers to organizational change to support health literacy. Because they were part of the same system and functioned under the same administration, policies and resources, the three clinic locations were analyzed as a single entity. The clinics were also in nearby towns and served similar population and often shared clinical and nonclinical staff and providers. The Saint Louis University Institutional Review Board approved the study, and informed consent was obtained from all interview participants.

Results

Thirty-five in-depth interviews were completed with two administrators, four clinical support staff, five of the six system providers, and eight nonclinical support staff. Sixteen interviews with patients were completed. Thematic saturation was reached; later interviews with patients, clinical and nonclinical staff and providers introduced little new information. There were too few administrators within the organization to reach this saturation level with administrators. Environmental audits were conducted during clinic operating hours by two researchers at each of the three clinic sites. Thematic facilitators and barriers to organizational health literacy are presented, accompanied by quotes or observations to illustrate each theme.

Facilitators

Overall, the needs assessment revealed high morale among all clinic staff. In the clinic, there is a culture of providing quality service and good communication with patients. The existing positive clinic environment and enthusiasm presented an opportunity to introduce new health literacy activities and organizational changes. The observations showed that all patients were greeted within five minutes of their arrival, that there was always a staff member available to answer the phones and in two clinic sites, all staff were wearing name badges.

It's an atmosphere of the patient comes first. Although we operate in a business model the patient needs come first. We'll sacrifice other issues to make sure the patients have what they need. (Provider)

In addition, there was a high level of satisfaction with the clinic and clinic staff reported by patients.

They're very friendly and down to earth. I've been to doctors … that they kind of … you know, I'm a doctor, you're not type of thing, and they kind of talk down to you. They're not here, they … talk to me like a person, I guess it's the only way I can describe it. And I've worked for doctors too, so I kind of know how it goes (laughing). (Patient)

The needs assessment revealed that some health literacy practices were taking place at the clinic. However, because of the unfamiliarity among many of the staff with the term “health literacy,” many staff who were already engaging in these activities did not recognize them as being related to health literacy. Instead, staff attributed health literacy practices to “common sense.” Similarly, the observations indicated that the staff answering the phones at all three locations used plain language, except when mentioning the name of specialties (e.g., “orthopedics”).

I think the staff does recognize those issues … Even if they don't title them as health literacy issues, I think our staff is trained well enough to recognize issues … They don't call it that, they understand. And they communicate with each other: provider to nurse or nurse to front office staff and say hey this patient needs a little extra help. (Administrator)

I think they've also identified sometimes if a patient hasn't said anything they watch them in the waiting room and they can tell if they're struggling or having difficulty. If it has been a while and they've not been able to get it back to them they'll approach them and offer their assistance. (Administrator)

Patients reported being able to locate educational print materials, and patients also reported positive feelings toward receiving and using print materials. Observations of the clinics’ physical environment indicated that there were many materials posted, some of which were well placed and informative.

Just anything they give me. You know, all those shot papers, I actually still have them from her … all her shots, all my other kids’ shots. I keep it all so I have reference material. (Patient)

However, some providers were skeptical regarding the use and utility of print materials by patients.

I have often thought about when we pass out patient information going to the trash can out front and opening up at the end of the day and seeing what the ratio of information is that is actually making it past the trash can out front. (Provider)

In interviews with providers, the needs assessment revealed that clear communication with patients is a high priority. Providers already practice several communication strategies, such as using plain language, using the teach-back method, drawing pictures, and taking the time to explain information to patients. Given prioritization of these current practices, there were opportunities to improve current patient–provider communication.

No I think we try our best to use normal language and language that they are going to understand. Not just the medical terms for everything, because they're not always going to understand that. (Clinical support staff)

The needs assessment also indicated that the clinic administration is very supportive of open communication among staff members, which is anticipated to support the dissemination and implementation of health literacy activities and organizational change within the clinic. More specifically, several staff members mentioned staff meetings as opportunities for discussions. In addition, the administration was supportive of the project objectives in general, and saw value in adding or enhancing organizational health literacy elements.

Well, we are encouraged to meet whatever our patients’ needs are. Health literacy would be a part of that, so we are encouraged to find data, find ways of communicating. You know if we need resources that are reasonable and cost-effective. (Provider)

Barriers

The awareness and understanding of the concept of health literacy was limited and highly varied among clinic staff. While the staff used common language when speaking with patients, observations revealed the use of some medical jargon (e.g., “pulmonary function test,” “liable”)

I don't know. I don't know what it means at all—health literacy. I really don't. (Nonclinical support staff)

Some staff reported uncertainty regarding their current role in interacting with other clinic staff, or gaps and inefficiencies in the process of moving patients throughout the clinic, especially for sharing health literacy-related information of a patient. Also, providers reported a need for increased time to spend with patients. Although the clinics designated a health educator, they were underutilized. This uncertainty led to the call for improved staff interactions through organizational changes, such as policy additions or changes.

Well as providers we don't have the time to be the only source of information for these people. And we don't always have the time to seek out or locate printed materials for them to take home and come up with questions for it when they come back. You know, just having what I think is an important conversation with these patients; we don't have time to do that as well. As providers we just don't. Yes we're the ones that understand it the best, so I think that's kind of sad. (Provider)

There were also no standard provider protocols for providing health education to patients. For example, there was no procedure for selecting, reviewing, or distributing patient print materials. This finding was supported by the clinic observations as well; while the clinic provided a lot of print material, the organization and quality of the materials varied greatly across clinic locations. Further, none of the clinics was observed to use technology-based patient education. The TVs in waiting rooms, if they were turned on, were used for entertainment and not for educational purposes. There were no kiosks, computers or telephones for patients that offered patients health related information.

What printed materials we do have … We try … I guess they're at more or less a sixth grade level, as far as the grammar or the English. Actually I haven't taken the time to really analyze that. I know as providers we keep it very, very basic. Because overall our education level here is not high, in our population. (Provider)

Staff reported having received limited formal training from within the clinic setting. Rather, training took place “on-the-job.”

But I also like to have them work with several of the staff members in that area and to just have them partially learn by observation and watch their communication skills. There are some areas that we do some formal training in—HIPAA and different areas like that. But as far as communication with patients we don't do a formal training with them when they first start. It's something they sort of up pick up and learn. (Administrators)

Providers reported that noncompliance among patients was a barrier to effective patient care at the clinic. But some patients reported either not understanding, not receiving it or having forgotten their diagnosis immediately following an appointment with a provider.

I think that I still couldn't tell you what my diagnosis was since he didn't tell me and it is not even written down on my slip for work. So I guess that would come in a little handy. (Patient)

Most clinic staff reported that there are no written or formal policies, especially policies that concern health literacy. Rather, policies are conveyed as informal expectations to conduct excellent work and provide excellent patient care. Some clinic staff expressed that policies are not necessary.

There are barriers in our business as there are in any. And I don't think it's necessarily a policy or anything that's put in place here. If anything inhibits it or provides a barrier is simply the volume of patients that we need - the need for all of the patients to have access. Meaning maybe the staff or the provider might feel a little rushed. Okay I've got 15 more patients to see I need to move this along. I don't think it's necessarily an organizational policy that inhibits it I think it's just the nature of working in a rural community with limited resources. (Administrator)

Collaborative Strategic Plan

After the academic team performed data analysis, findings were presented to the entire medical center staff for discussion. This discussion informed ideas for strategic planning activities, which were subsequently prioritized by members of a selected task force representing all clinic staff types. The identified barriers of limited awareness of health literacy in general, lack of recognition of current clinic practices as health literacy activities, and narrow understanding of contextual health literacy, directly informed one of the first activities to take place at the clinic: an overall orientation to health literacy and organizational elements of health literacy.

The needs assessment also illuminated the fact that patients and physicians value print materials differently and also that the clinic did not have a specific process for selecting such materials. Physician skepticism about the usefulness of the materials and the patients’ endorsement of them suggested an opportunity to build upon current clinic practices in selecting and distributing print materials. Thus, the strategic plan included establishing tools and processes for systematically reviewing and standardizing patient education materials.

The clinic culture was very supportive of open communications and of the role of health literacy, but there was not a mechanism for staff to learn more about health literacy and related activities. Staff meetings were identified as opportunities to discuss the health literacy and organizational changes during and after the project. The staff and providers were also clear that presenting resources for both health literacy information and health literacy training opportunities to the clinic staff should be included as a strategic activity.

One of the primary themes that emerged from the needs assessment was that the patients were not altogether clear about their diagnosis, and perhaps because of this there was a high degree of patient noncompliance with treatment plans. After some collaborative discussion, the team agreed to develop a form for patients to use to record the physician discussion, the outcome of the visit, and the recommended treatments.

Discussion

The customized instruments were successfully used to conduct the needs assessment, which then led to collaborative strategic planning. In a clinic with limited resources serving high-needs populations with a high prevalence of chronic disease, the instrument allowed for open-ended interviews and environmental observations to be completed. Through the use of this elicitation process we generated not only a useful catalogue of suggested health literacy practices that might be generally considered by the clinic's system, but we were also able to prioritize these indicated practices in light of organizational assets, needs and culture. More than a universal assessment approach, our needs assessment better positioned the key stakeholders to participate in the strategic planning process. Using open-ended assessments that probed for relevant organizational dynamics, the action planning process was more efficient and hypothesized to lead to greater sustainability.

The needs assessment identified primary facilitators and barriers to implementing organizational changes to support health literacy. Facilitators included the fact that there was high morale at the clinic, the patients were very satisfied and the clinic as a whole recognized the importance of clear communication and patient education. These assets were leveraged in the strategic plan and the action steps built upon these facilitators. For example, because the patients reported such high levels of satisfaction, the staff felt comfortable adopting new practices, even when those may have initially increased patients’ time in the clinics.

The barriers to change included the lack of formal protocols or policies to support health literacy practices, the ambiguity of role among clinic staff and the lack of knowledge or training about health literacy. Not only were these gaps addressed in the strategic plan, but the plan also acknowledged the informal organizational culture and therefore used guidelines and recommendations rather than strict policies.

We encourage future research and practice to apply such customized assessments for organizational health literacy by using the approach described here or by developing tools that meet the needs of a different setting. It is important to note that the assessments should include the domains most relevant to the setting and should build upon recent work describing attributes of a health literate organization (Brach, 2012), allow for probing of organizational assets, and result in a focused action plan to guide subsequent efforts.

However, we offer a few cautions to those using this approach. First, the selection of times for the environmental assessment may affect the interpretation of results. For example, in low-traffic periods, environmental observations may indicate greater attention to health literacy than during high-traffic times. To the extent possible, these environmental assessments should take place at different times. Also, the lack of common and in-depth understanding of the concept of health literacy may lead to the inability of staff or patients to comment on health literacy in general, or about current, unrecognized health literacy practices (or lapses) in the clinic. To this end, practitioners might assist clinic staff in identifying practices related to health literacy domains, such as their communications with patients, or the print materials they use. Last, several domains we identified initially were later determined to be irrelevant, which may be the case in future applications. For example, in a clinic that has minimal needs for interpreters, lack of translation services should not be assessed as a gap in services. It is important for those assessing health literacy needs of organizations to first determine the domains of interest so that the assessment effort can be efficient and focused on establishing priorities among relevant tasks.

The needs assessment successfully assessed several barriers and facilitators to health literacy, which informed the strategic plan for implementation and evaluation. This allowed all stakeholders to understand the complexity of the problem and the elaborate constellation of factors that influence health literacy practices. The strength of the approach presented here is that it builds on the relevant domains from established instruments, focuses strategic planning efforts based on barriers and facilitators to structural, organizational change and can be applied in collaborative manner in a clinic setting. Although various individual level health literacy activities are essential, their efforts will be maximized if the institutions in which they are implemented value and support such efforts. This collaborative approach between research and clinic practitioners can help ensure that they are.

Acknowledgments

This project was funded by the Missouri Foundation of Health, grant 08-0638-HLD-09, and could not have been completed without the collaboration of the administration, staff and providers at the Great Mines Health Center, Potosi, Missouri. The authors thank Rima Rudd for her review of an earlier version of this article.

Notes

^a Administrative, provider, clinical support, and front desk staff.