AMA tool kit helps doctors measure, boost patient comprehension

By Kevin B. O’Reilly

Nine hospitals and physician practices around the country are testing a set of surveys to help them assess how well they communicate with patients, especially those with limited English proficiency or low health literacy. The surveys are part of an American Medical Association tool kit launched publicly in late April.

The communication problem appears grave: More than 95 million Americans do not read well enough to understand a prescription label. More than 34 million patients were born in other countries, and more than 22 million do not speak English “very well,” according to a 2006 report from the AMA’s Ethical Force Program, which created the tool kit.

These patients, studies show, obtain preventive care services less often, are more likely not to take medication as directed, and have worse health outcomes. Yet the challenge for physician practices and hospitals is to determine how well they care for these patients who often are too embarrassed to admit that they do not understand forms or that they struggle to communicate with doctors, nurses and receptionists.

The tool kit — funded by a four-year, $688,000 grant from the California Endowment — features short, easy-to-understand patient surveys as well as surveys intended for executive leadership and clinical and nonclinical staff.

Patients are asked to rate experiences in understanding receptionists, signage, educational materials and forms, and communication with doctors and other health care professionals. The staff surveys focus on how well the hospital or practice provides interpreter services and training.

While doctors do their best to speak in terms patients understand, that may not be enough, physicians said.

“It’s important that the clinic as a whole sees how it communicates with patients,” said Kelly S. Bossenbroek, MD, a family physician at a Meriden, Conn., health center that is part of the 11-clinic Community Health Center Inc. involved in field testing the tool kit.

“Unless you have actual data, you can’t tell if you’re getting better and you don’t necessarily know where your problem areas are. That makes it difficult to make improvements.”

Nearly 1,400 patients, 80 clinical staff and more than 100 nonclinical staff have filled out surveys. The process has been a learning experience, said Debbie Ward, a nurse manager and member of CHC’s quality improvement committee. When administering surveys to patients in waiting rooms, Ward discovered that some patients were illiterate.

The clinics already have a language phone line available in each exam room for interpretation services and are working to implement the so-called teach-back method, in which patients are asked to say in their own words the message a doctor has just given. Because physicians may be too busy to go through teach-back with patients, CHC clinics often delegate the job to nurses.

Another group that is using the communication tool kit is the Mount Pocono, Pa., physician practice that is owned by Geisinger Health System. Between 30% and 40% of the practice’s patients speak English as a second language or come from culturally diverse backgrounds, said Wenda Hartzell, a Geisinger Health System administrator. Hartzell said the surveys helped bring about change.

“What we realized is there are certain things you need to have in place for sites serving diverse populations,” she said. “We are looking at providing signage and sign-ins in Spanish and other languages.” Hartzell said Geisinger plans to test whether the changes improve patient perceptions and health outcomes.

The AMA welcomed use of the tool kit. “These experiences demonstrate how the Ethical Force tool kit brings together communication and quality improvement in a unique and valuable way,” said AMA trustee Edward L. Langston, MD.

More broadly, measuring the caliber of communication helps translate the ethical imperative to share decision-making with patients into action, said Paul M. Schyve, MD, senior vice president of the Joint Commission and chair of the Ethical Force Program’s oversight body.

“When we talk about ethical issues, often they feel more amorphous and not as clearly defined as other things we think about in the science of medicine,” Dr. Schyve said. “[The tool kit] is an attempt to try to say, can we first agree on what is the basic principle, then can we start to become concrete about whether that principle’s being played out in my clinic, my practice, my hospital.”

The surveys can be downloaded for free (

The tool kit, including promotional materials and data templates, costs $250. More extensive services run up to $5,500.

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