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Improving health literacy improves patient outcomes​​​​

Imagine giving a patient or client discharge instructions only to find that patient or client injured himself as a result of not following your instructions correctly. As a healthcare provider, you recall the patient shaking his head indicat­ing “no” when you asked, “Do you have any ques­tions?” What happened? The answer is that like many healthcare provid­ers, you probably overestimated the patient’s health literacy. 

According to a 2003 report from the Department of Health and Human Services (the most recent available data), only 12 percent of U.S. adults have “proficient” health literacy, meaning they can understand and use health information effectively, and more than a third have only a limited level. That translates into millions of people in the United States who don’t understand the vital health information healthcare providers give them. To change that paradigm, healthcare providers need to recognize the issue of health literacy and use tools such as “teach-back” and patient-friendly education materials to help ensure comprehen­sion. 

The value of health literacy 

Ensure that patients understand instructions so they can manage their own care and improve out­comes. February 2012’s Health Affairs cites stud­ies of strategies that improve patient adherence. For instance, medication counseling using a plain language, pictogram-based intervention resulted in fewer dosage errors and greater adherence, compared to standard care, which is considered routine verbal counseling about the medication. 

Three 2010 initiatives recognize the vital role of health literacy—The Affordable Care Act, the National Action Plan to Improve Health Literacy from the Department of Health and Human Ser­vices, and the Plain Writing Act. Effective July 1, 2012, The Joint Commission’s new standards on patient-centered communication also includes guidelines on health literacy to assist practitioners in making their communication effective, minimiz­ing risk. These initiatives have prompted facili­ties to develop policies related to health literacy, which healthcare providers need to use to guide their practice. 

The current healthcare environment is a place where healthcare professionals will be held ac­countable for meeting their clients’ health literacy needs. Legislation, facility policies, and standards of practice could be cited in litigation involving mishaps related to a patient’s taking incorrect action because he or she didn’t understand the provided information. 

A “universal” resource 

You can’t tell a patient’s health literacy by look­ing at him or her. However, in this busy world of healthcare, there is little time to conduct a for­mal assessment. That’s why the North Carolina Program on Health Literacy says that just as we use universal precautions to prevent spread of bloodborne disease for all patients, we need to use health literacy universal precautions for all patients. 

The program developed the Health Literacy Universal Pre­cautions Toolkit, available as a free download at www.nchealth­ The toolkit, commissioned by the Agency for Healthcare Research and Qual­ity, includes steps that healthcare providers can easily implement in their practice, including selecting provided tools, applying them, and assessing how effective they were in the interaction with the patient. Tools include how to use teach-back (see The power of teach-back), a reminder of key communication strategies, and a handout of systems patients can use to keep track of their medications.

Boosting understanding 

You can use several simple strategies to address health literacy when working with patients. For example:

  • Ask a patient how he or she prefers to receive information (by reading, hearing, or seeing). 

  • Avoid medical jargon and speak in simple, easy-to-understand terminology. 

  • Speak slowly, so patients can more easily absorb the information. 

  • Encourage patients to participate as you teach. For example, you might have the patient hold the syringe as you are talking about it. 

  • Repeat key points. 

  • Use pictures, if possible, to help explain concepts. 

  • Don’t try to cover too much in one session.

  • Document the communication methods used in the patient’s medical record. Another tip for promoting communication is Ask Me 3,TM which encourages patients to understand the answers to three questions: 

  • What is my main problem? 

  • What do I need to do? 

  • Why is it important for me to do this? 

Encourage your patients to keep asking healthcare providers for information until they can answer those questions. 

A team approach 

Any method you use, from speaking slowly to encouraging questions, will help patients be more informed. More informed patients are less likely to sue because they are able to follow instructions and give themselves the best opportunity for successful self-management. By developing trust and promot­ing open communication, healthcare providers can address health literacy and build a relationship with their patients that achieves the best possible outcomes. 

The power of teach-back 

If asked, “Do you understand?” after receiving health information, most patients will say yes rather than admit their lack of knowl­edge. “Teach-back” is a powerful method that ensures a patient truly comprehends what you have said. In this method, ask him or her to “teach” you the information. For example, you might say to a postoperative patient being discharged from the ambulatory care center, “I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine?” 

Teach-back can help you ensure that the patient understands the information you provided so he or she is more likely to adhere to instructions, thus reducing the likelihood of complications and a possible lawsuit. 

Source: North Carolina Program on Health Literacy. Health Literacy Universal Precautions Toolkit.


The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals. Accessed Feb. 6, 2012. 

National Quality Forum. Cultural competency: An organizational strategy for high-performing delivery systems. No. 14, April 2009.

Koh HK, Berwick DM, Clancy CM, et al. New Federal Policy Initiatives to Boost Health Literacy Can Help the Nation Move Beyond the Cycle of Costly ‘Crisis Care.’ Health Affairs. 2012;31(2):434-443. 

National Patient Safety Foundation. Ask Me 3. Accessed Feb. 10, 2012. 

North Carolina Program on Health Literacy. Health Literacy Universal Precautions Toolkit. Accessed Feb. 10, 2012.​

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