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Strategies to Improve Organizational Health Literacy.

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Elizabeth Seidel, MSW, Tara Cortes, PhD, RN, FAAN, and Cynthia Chong, MPA | May 31, 2023
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Background

Health literacy is important at both the personal and organizational levels. According to Healthy People 2030, personal health literacy defined as an individual's ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Organizational health literacy complements personal health literacy. Its definition is: the degree to which an organization equitability enables individuals to find, understand and use information and services to inform health-related decisions and actions for themselves and others. Failure to incorporate health literacy principles into an organization can lead to miscommunications and barriers that result in patient safety events. Errors in care and adverse events associated with health literacy include mistakes in diabetes management;1 taking the wrong dose or mixing up medications;2 errors in dosing and administration of medications for children;3 incorrect use of inhalers and aerosol medications;4 falls; delays in receiving treatment, surgery, or tests; and wrong procedure or wrong site surgery.

Achieving organizational health literacy is a Healthy People 2030 goal and access to health literate organizations is a social determinant of health. Health literate organizations help people better navigate complex health systems, impacting healthcare delivery and outcomes.

Reasons to Adopt Health Literacy Universal Precautions

Health literacy universal precautions takes the perspective that all patients may have trouble understanding health care instructions. Therefore, taking health literacy universal precautions means organizations should structure healthcare, including instructions, patient education, and handouts, as if everyone has difficulty understanding health information and accessing healthcare services. It’s just like we take blood safety universal precautions–we treat all blood as if it’s infected because we don’t know which blood is infected.

One reason to adopt health literacy universal precautions is that many people struggle with understanding and acting on health information. The only nationally representative survey of health literacy, conducted by National Center for Educational Statistics in 2003, tested adults’ ability to use printed health information and found a third of Americans had basic or below basic levels of health literacy, 53% had an intermediate level, and only 12% had a proficient level of health literacy.5 People with limited health literacy come from all walks of life and you can’t tell by looking who they are.

Another reason is that health literacy is dynamic and varies depending on several factors, such as a whether person is tired, frightened, or ill. What is more, everyone – even well-educated, knowledgeable people – appreciate clear communication and services that are easy to access. Healthcare systems should therefore implement universal precautions that assume everyone is at risk of limited health literacy.  

Health Literacy Strategies for Organizations

Health literacy is integral to the mission, structure, and operations of a healthcare organization. Organizations can use the following strategies to incorporate health literacy into to all aspects of their services:

  • Conduct an Organizational Health Literacy Assessment: Conduct an organizational health literacy assessment that examines current health literacy procedures such as the creation of patient materials and staff training. Assessments can be specific to the setting (e.g.,  Pharmacy Health Literacy Assessment Tool, Primary Care Health Literacy Assessment) or generic (e.g., Health Literate Health Care Organization-106 or the Health Literacy Environment of Hospitals and Health Centers [HLE2]7) Develop organizational health literacy plans using quality improvement measures.
  • Train Staff in Health Literacy: Train the workforce at every level of the organization on health literacy best practices.
  • Create a Welcoming Environment: Create a shame free environment and provide resources. Offer assistance with filling out forms and training on the patient portal. All patients should feel welcomed and comfortable at each stage of the health care encounter – from the telephone, to the reception area, to the finance area, and finally to the examination, procedure, or inpatient room.
  • Improve Spoken Communication: Organizations’ health literacy plans include processes to ensure clear communication, including (1) Using plain languages and visual aids, such as models, pictures, or videos, (2) Providing explicit instructions, (3) Offering only the information patients need by limiting the discussion to 3-5 key points, (4) Listening carefully without interrupting patients and use words the patients use to describe their health or illness, (5) Encouraging questions to engage patients as active partners in their healthcare, (6) Confirming comprehension using the teach-back or show-me method, (7) Being sensitive to the culture, customs, and beliefs of patients and (8) Providing qualified interpreters and clinical staff certified to deliver care in languages other than English
  • Simplify Written Communication: Choose or create written materials in multiple languages that are easy to understand and act on. Organize information using informative headings for each short section. Create materials with short sentences, simple words, and clear images that reinforce rather than distract from the messages. Have processes in place to review materials with patients.
  • Bridge the Digital Divide: Incorporate digital health literacy strategies8 such as determining patient access to technology, promoting technology adoption, and offering technical support. Make websites, apps, and patient portals easy to access, navigate, and understand. Offer access sites such as kiosks for patients that do not have a personal device. Increase the digital health literacy of patients through education on detecting reliable health information online.
  • Make Healthcare Navigation Easy: Improve support for navigating healthcare facilities and systems: Design signage so it is easy to understand and use. Provide alternatives to written and digital information. Assist patients with accessing the care they need (e.g., making referrals easy) and understanding healthcare bureaucracy and costs.
  • Support Patients’ Health Management Efforts: Have processes in place for providers to develop action plans with patients that will help them achieve their goals safely and reinforce what patients are doing well. Provide pill organizers and simple guides for medications and other self-management practices.

The Health Literacy Online website offers a variety of helpful information in how to simplify your process and resources as well as how to engage patients.  

Becoming a Health Literate Organization

Health literate organizations weave health literacy into all of their processes from patient education to monitoring and evaluation. A National Academy of Medicine discussion paper9 identifies and describes essential attributes of a health literate healthcare organization including leadership creating the capacity for planning, implementing, and evaluating organizational health literacy; preparing the workforce; making access to health information available to populations served; and addressing health literacy in high risk situation such as when patients are prescribed medications or are discharged from the hospital. The Agency for Healthcare Research and Quality has developed a wide array of health literacy tools and resources to help organizations improve safety and quality.

Elizabeth Seidel, MSW
Program Manager
Hartford Institute for Geriatric Nursing
NYU Rory Meyers College of Nursing

Tara Cortes, PhD, RN, FAAN
Professor of Geriatric Nursing

NYU Rory Meyers College of Nursing

Cynthia Chong, MPA
Project Coordinator
Hartford Institute for Geriatric Nursing
NYU Rory Meyers College of Nursing

References

  1. Marciano L, Camerini AL, Schulz PJ. The role of health literacy in diabetes knowledge, self-care, and glycemic control: a meta-analysis.  J Gen Intern Med. 2019;34(6):1007-1017. [Free full text]
  2. McCune RL, Lee H, Pohl JM. Assessing health literacy in safety net primary care practices. Appl Nurs Res. 2016;29:188-194. [Available at]
  3. Vaillancourt R, Cameron JD. Health literacy for children and families. Br J Clin Pharmacol. 2022;88(10):4328-4336. [Available at]
  4. Mira JJ, Lorenzo S, Guilabert M, et al. A systematic review of patient medication error on self-administering medication at home. Expert Opin Drug Saf. 2015;14(6):815-838. [Available at]
  5. Kutner M, Greenberg E, Jin Y, et al. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Education Statistics; September 2006. [Free full text]
  6. Singer D, Howe C, Adame T, et al. A Psychometric analysis of the Health Literate Healthcare Organization-10 Item Questionnaire. Health Lit Res Pract. 2022;6(2):e137-e141. [Free full text]
  7. Rudd RE, Oelschlegel S, Grabeel KL, et al. The HLE2 Assessment Tool. Boston: Harvard T.H. Chan School of Public Health. 2019. [Free full text (PDF)]
  8. Conard S. Best practices in digital health literacy. Int J Cardiol. 2019;292:277-279. [Available at]
  9. Brach C, Keller D, Hernandez LM, et al. Ten Attributes of Health Literate Health Care Organizations. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2012. [Free full text]
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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