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Tool 4: Communicate Clearly

The goal of this tool is to introduce your practice to effective oral communication strategies as they interact with patients.

Tips for Administering Communication Assessments

• Lay the groundwork for the self-assessment by explaining that the intention is to help clinicians and non-clinicians honestly evaluate their oral communication with patients, and identify areas for improvement.
• Administer the Communication Self-Assessment to all members of your practice staff, including clinicians, medical assistants, and front and back office staff. Consider enlisting the help of a practice leader (e.g., medical director, lead physician) to endorse the completion of the assessment, particularly with other clinicians.
• Ask a respected individual in your practice to conduct observations of provider/staff interactions with patients before and after tool implementation. Use the Communication Observation Form to provide feedback to practice staff, including clinicians, medical assistants, and front and back office staff about the quality of their communication with patients. As you observe an interaction, complete the form and write notes that can help the provider or staff member improve his or her communication in the future.
• The Patient Feedback Form can be used by patients to provide honest feedback about the communication skills of practice members. 
• These assessments can be administered in hard copy. The self-assessment can also be administered by email as an MS Word document. Consider what modality will be easiest for your practice members to use and how you plan to receive the assessments and use the information to determine if your staff is making improvements.
• If you anticipate needing help in tallying up and making sense of the assessment results, consider constructing an online survey.

Tips for Using the Assessment Results

• Assessment results are intended to help your practice members set goals to improve their communication skills with patients. As such, these assessments can be repeated as often as necessary until personal goals have been reached.
• The health literacy team should collect completed assessments after 1 or 2 weeks—long enough to have about 5 assessments per individual.
  • Create a brief personal report that summarizes the most important observations from the completed assessments (e.g., areas of strength and areas for improvement, differences in skills observed over the duration of the week).
  • Distribute each report to individual staff members.
  • Invite practice staff to meet with a member of the health literacy team to discuss their results and feedback generated from the assessments. This is a great opportunity to provide individualized suggestions for improving communication skills.

Other Strategies for Implementing Tool 4

• Use educational sessions and training opportunities to increase staff awareness about key communication strategies. (Go to Tool 3: Raise Awareness). You can use team huddles to reinforce information about key communication strategies and to encourage completion of the Communication Self-Assessment.
• Place the Key Communication Strategies Poster in areas where front and back office staff members are likely to see it and be reminded of the communication strategies they should be using. 
• Tool 4 lends itself well to role playing. Practice members can role play with each other how they would communicate with a patient while performing an ordinary task (e.g., explain a blood test, give directions to a referral location). Invite a patient or family representative to participate in the role playing exercise and provide feedback.
• Offer communication coaching services. Staff can request that a coach observe their communication with patients and give them feedback. Make sure the communication coach knows how to give tactful and constructive feedback that includes singling out praiseworthy communication practices.
• Refer practice members to for tips on avoiding use of medical jargon when communicating with patients.

Tool 5: Use the Teach-Back Method

The goal of this tool is to provide your practice with examples and helpful advice on performing the Teach-Back Method. Teach-back is a way to confirm that you have explained to your patients what they need to know in a manner that they understand by asking the patient to explain the information back to you.

Tips for Training Staff on Teach-Back

• Use educational sessions and training opportunities to teach staff how to use the teach-back method. (Go to Tool 3: Raise Awareness) You can draw from the materials provided in the Toolkit.
• For staff or residents who cannot attend training sessions or who need additional reinforcement, use the provided in the Toolkit.
• Use role-playing by having one practice member play a provider giving medical instructions, and another play the role of a patient being asked to teach this information back.
• Designate one person from each area of your practice (look to your health literacy team members) to provide additional teach-back training to their colleagues and to actively encourage their use of this communication method.
• Brainstorm specific ways to apply teach-back to staff member interactions with patients. Record these examples and present them at future staff meetings. This can be especially helpful with non-clinical staff members, for whom it may not be as obvious how teach-back can be used (e.g., what to bring to the first appointment, review of payment arrangements).
• Directly address practice members' concerns about not having time to do teach-back.
  • Explain that teach-back is not something you add onto a visit when you've done everything else. Experienced users of teach-back report that they integrate teach-back into the visit in a way that doesn't take extra time.
  • When a patient has difficulty understanding, teach-back can take a couple of extra minutes, but underscore that teach-back is a good investment. For example, if teach-back had not been used, the patient might not have taken medicine correctly, followed up on a referral, or followed through on self-management tasks.
  • Find practice staff members that can augment teach-back conducted during the clinician's visit. For example, could a medical assistant or nurse conduct teach-back after the clinician has left the exam room?

Tips for Using and Tracking the Use of Teach-Back

• Use the teach-back question on the Communication Observation Tool in the Toolkit to track your progress.
• Designate one day of the week to emphasize teach-back, such as "Teach-Back Tuesdays." This reminds staff that on this day they should practice their skills with every single patient and track their progress. It helps build awareness as teach-back becomes part of your practice's culture.
• The key is to keep practicing. The goal is to make teach-back a routine and consistent method used by all members of your practice.

Tool 6: Follow Up With Patients

The goal of this tool is to outline options for following up with patients.

Tips for Implementing this Tool

• Consider implementing Tool 6 with other tools from the Toolkit. For example, followup is critical to the implementation of these tools:
  • Tool 15: Make Action Plans instructs practices to follow up with patients to see if Action Plan steps have been completed or need to be adjusted or augmented.
  • Tool 18: Link Patients to Non-Medical Support, Tool 20: Use Literacy Resources in the Community, and Tool 21: Make Referrals Easy all include followup to make sure patients connect with resources outside the practice
• In addition, other tools, such as Tool 4: Communicate Clearly and Tool 5: Use the Teach-Back Method, should be used when performing followup.
• The challenge for your practice will be coordinating these various efforts. When implementing this tool, the health literacy team may want to consider:
  • Asking patients how they prefer to be contacted and receive messages. Record the information in the patient's medical record.
  • How to minimize the number of contacts with the patient. For example, if someone in the practice is calling to check in on an action plan, could they also confirm that the patient is taking medicine correctly? This is efficient for both the practice and the patient.
  • Use Module 5: Mapping and Redesigning Workflow in AHRQ's Practice Facilitation Handbook for further guidance on aligning followup activities in your practice.
• Develop scripts and model emails and texts for staff to use when following up with patients.
• Investigate the functionality of your electronic health record and patient portal to see if some aspects of followup can be automated.

Tool 7: Improve Telephone Access

The goal of this tool is to help practices manage their telephone systems and develop procedures for telephone contact.

Tips for Implementing this Tool

This tool is a great one for front and back office staff to take on while clinicians are working on other tools.

• Create a work group of front and back office staff and the patient on your health literacy team to work on this tool. If you want to consider installing a new phone system, include staff who have the authority to make that decision.
• Hold training sessions on Tool 4: Communicate Clearly and Tool 5: Use Teach-Back specifically for front and back office staff. Trainings for these tools often focus on clinical examples that don't feel relevant to these staff members.
• Make sure supervisors are on board and reinforce changes.
• Develop a protocol for when speakers of languages other than English call. For example, staff could have a cue card with the phrase "Please wait a moment" in commonly spoken languages and the extensions of bilingual staff and the phone number to call for telephone interpreters.
• Document changes that result for improving the telephone system, such as less time transferring calls, fewer missed appointments, greater job satisfaction of staff who cover phones.

Tool 8: Conduct Brown Bag Medicine Reviews

The goal of this tool is to develop a process for your practice to improve communication about medicines between patients and clinical staff by asking your patients to bring their medicines to appointments and reviewing their medicine with them. Implementation of this tool resulted in some important improvements in the medicine reconciliation process. Patients who are struggling to understand how to take the right dose of medicine at the right time may have limited math skills. You may want to consider implementing this tool with Tool 20: Connect Patients with Literacy and Math Resources, which gives guidance on connecting patients with math resources in the community.

Tips for Getting Your Practice Ready

• Use educational sessions and training opportunities to raise awareness about health literacy and introduce the importance of conducting medicine reviews (Go to Tool 3: Raise Awareness). Use these sessions to garner staff support, seek feedback on your implementation plan, and provide regular updates about your progress.
• Order medicine bags, and encourage patients to use them to bring in their medicines. When ordering bags, think about getting grocery-size bags with your practice name/logo on them. The bags may also serve as a reminder to staff and reinforce the importance of medicine review.
• Order appointment cards that have printed reminders about bringing medicines to every visit. Alternatively, you can attach reminder labels to existing appointment cards. Remember that patients should also be asked to bring medicines as part of reminder phone calls.
• Involve as many practice areas as possible in implementation activities. This will facilitate changes in workflow and send a message that everyone in the practice has an important role to play.  Different staff members can play a role in medicine review:
  • Schedulers remind patients to bring their medicines to each appointment and hand out medicine bags and appointment cards with a printed reminder.
  • Receptionists praise patients upon arrival when they bring their medicines.
  • Rooming nurses thank the patient for bringing in their medicines and place all medicines on the counter in the exam room to remind the clinician to perform a medicine review.
  • Clinicians conduct medicine reviews, check medicine lists in the electronic health records (EHRs) and reconcile the lists at each appointment, print out current medicine lists for patients, and document review and reconciliation activities in the EHR.
  • Clinicians conducting the review praise patients for bringing their medicines and emphasize the importance of doing this at each appointment.
• Have a fallback position if clinicians tell you they don't have time to conduct brown bag medicine reviews for every patient at every visit.
  • Prioritize patients that are at highest risk for medicine errors. For example, patients who take multiple medicines or medicines that are dangerous if taken incorrectly, have cognitive impairment, report significant medicine side effects, or have known financial difficulties or health literacy limitations.
  • Establish appropriate intervals (e.g., annual) for medicine reviews for other (lower priority) patients.
  • Limit the frequency of medicine reviews to times when something has changed. For example, a new medicine is added, a medicine is discontinued, a change in dosage occurred, or the patient is seeing a new specialist.

Tips for Documenting Medicine Review

• If necessary, make changes to your EHR that allow you to document and later run a query to see when medicine review and reconciliation has occurred. Encourage staff to not only document if the activity took place, but also any problems that were identified during the review.
  • Often, serious medicine errors are caught during medicine reviews; by identifying and sharing these stories with staff you can help reinforce the importance of this tool and garner greater buy-in.
• Having friendly team competitions to see which practice team conducted and documented the most medicine reviews can help build awareness and increase the number of reviews being done and documented.
• Run regular queries of your EHR to determine how many patients have undergone medicine review and reconciliation. Report these data back (at least monthly) to all practice staff to encourage their continued reviews.

Tool 9: Address Language Differences

The goal of this tool is to help practices meet the language needs of all patients. Speakers of languages other than English, including speakers of American Sign Language, often do not get the health information they need.

Tips for Training

• Teach front desk staff how to ask about language preferences and language assistance needs, and to standardize documentation in the health record. Questions can include:
  • How well do you speak English? Very well, well, not well, not at all? (Anything other than "very well" requires language assistance.)
  • What language do you feel most comfortable speaking with your doctor or nurse?
  • Would you like an interpreter?
  • In which language would you feel most comfortable reading medical or health care information?
• Instruct front desk staff to always check the health record for communication needs when making appointments. If needed, arrange for interpreter services at the same time as the appointment is scheduled.
• Teach staff that if there's any doubt about English proficiency, they should call for interpreters.
  • Staff often think they are being understood if the patient speaks some English, or speaks English very well when speaking short sentences.
  • Even when patients are normally proficient in English, they may have difficulty speaking and understanding English when sick or stressed.
  • Use teach-back to determine whether patients understand. (Go to Tool 5: Use the Teach-Back Method.)
  • Embarrassment may prevent patients from admitting that they don't understand, so staff may need to call for an interpreter even if the patient has said they don't need one.
• Ensure staff understand that untrained interpreters are more likely to make clinically significant mistakes than trained interpreters. Similarly, use of their own foreign language skills, if they are not proficient, can put patients at risk.
• Suggest ways staff can respond when patients want to bring or have brought their own interpreter. For example:
  • When making an appointment: "Our policy is to have a medically trained interpreter at your appointment. It won't cost you anything. The interpreter is for the providers and office staff. You and your provider can decide how best to use the interpreter when you come in for your appointment."
  • When friend or family wants to interpret: "Thank you very much for offering to interpret. However, our policy is to use our medically trained interpreters, which we provide for free. I'm sure your (relative/friend) appreciates your help, and today you can relax and be a supportive (daughter/son/husband/wife/friend) instead of being an interpreter."
  • When patients insist on their own interpreters: "Of course you can choose to have your (relative/friend) interpret for you. However, it's our policy to also have a medically trained interpreter with us. It won't cost you anything."
• Train staff how to obtain interpreters, including bilingual staff who have been trained as interpreters, qualified in-person interpreters, or telephone interpreters.
• Staff will work more efficiently and effectively with interpreters if they know practices that ensure good communication and safety. These include:
  • Briefing the interpreter ahead of time. Ask interpreters to let you know if they think there is not mutual understanding and to clarify terms with you (See 30-second video clips of an interpreter briefing and establishing "psychological safety" at http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/lep/videos/index.html) .
  • Speaking directly to the patient, not the interpreter, at a normal speed.
  • Pausing after every full thought for interpretation.
  • Not saying anything you don't want the patient to hear.

Tips for Planning

• Conduct an organizational self-assessment.
  • Identify all the areas of the practice in which the patient might interact with staff.
  • Prioritize important written materials for translation (e.g., intake forms, consent forms, medicine instructions, advance directives, billing information).
  • Review signage around the office and building, and consider whether bilingual or multilingual signage will help patients find their way. Test signs before making changes, as multilingual signs can be confusing for patients with limited literacy.
  • Look not only at your data on language assistance needs, but also at community data on languages spoken and English proficiency. Nearby residents who speak other languages may not be seeking care at your practice if there is no language assistance.
  • Assess your practice's capacity to provide services in other languages. Verify proficiency of bilingual staff to deliver services. Make sure that staff who will serve as interpreters for others are trained and certified as interpreters. Being an interpreter involves more than language skills.
• Develop a plan for meeting those needs. Don't forget to monitor and update the plan periodically.
• Prepare back-up plans, in case bilingual staff or on-site interpreters are unexpectedly absent. Also prepare for unanticipated language assistance needs (e.g., a patient arrives that speaks a rare language, patient prefers a woman clinician and the only bilingual clinician is a man).
• Schedule sufficient time for appointments when interpreters will be used. Using interpreters does not necessarily take more time than trying to get by without using interpreters, but is likely to take longer than patients who are proficient in English.
• If you are using bilingual staff who have been trained as medical interpreters, be clear about how the interpreter will be freed from other job duties while interpreting. Make sure that supervisors are on board with the plan.

Tool 10: Consider Culture, Customs, and Beliefs

The goal of this tool is to help practices work effectively with an increasingly diverse population of patients.

Tips for Implementing Tools in a Culturally Competent Manner

• Tool 3: Raise Awareness
  • Become aware of the cultural assumptions that we all make. Facilitate a discussion on how cultural biases affect our behavior and decisionmaking.
  • Bring in examples of how other cultures think about health and wellness (e.g., Asian and Latin beliefs about balancing hot and cold) as a reminder of the diversity of views.
  • Recognize that Western medicine has its own culture. We try to isolate the source of the problem and fix it. Learn about other cultures' approach to health and healing (e.g., holistic treatment of body, mind, and spirit).
  • Generate sensitivity to the fact that some groups are mistrustful of doctors. Communication of cultural understanding and respect can help you establish trust.
  • Promote an office culture that has zero tolerance for disrespect.
  • Learn which racial, ethnic, cultural, and religious groups reside in your community. If there is a concentration of a particular group, learn about the customs and beliefs of that group.
• Tool 4: Communicate Clearly
  • Remember that culture is an important part of everyone's identity. Even a patient who looks and sounds just like you may be coming from a very different place. Treat every visit as a cross-cultural encounter.
  • Be aware that verbal and non-verbal communication styles vary. Take your cues from your patient as to whether establishing eye contact or reassuring touching is comfortable.
• Tool 11: Assess, Select, and Create Easy-to-Understand Materials
  • Consider whether there are cultural assumptions inherent in your educational materials.
  • Check whether the pictures in your materials represent the diversity of your patients.
  • Ensure that you select diverse patients when soliciting feedback on your materials. Ask them specifically about any conflict with cultural norms or health beliefs.
• Tool 13: Welcome Patients
  • Choose diverse patients to shadow.
  • Assess whether people in posters displayed in the waiting and exam rooms look like your patients.
• Tool 15: Make Action Plans
  • Recognize the importance of the patient's cultural background and environment when negotiating goals and action steps.
  • Discuss whether customs or beliefs in the family or community could present barriers to completing action steps.
  • Be willing to collaborate with traditional healers. Patients are less likely to follow through on action plans if they perceive them to be in conflict with other advice they're being given.
• Tool 17: Get Patient Feedback
  • Connect with leaders of cultural and religious organizations that serve your community. Learn what respect looks like to them, what their primary health concerns are, and how your practice could better address their concerns. Engage organizations even when they represent few of your patients to learn why your practice doesn't attract more patients from that group.