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ED Accreditation Update
White paper underscores patient health literacy
" . . . Your left toe, looks like you're going to lose a little bit of the distal part," the trauma surgeon told the wounded patient. Then he paused, and rephrased: "The end of it, right at the toenails there; just a tip off the big toe and maybe the second toe in, just the tip."
This brief conversation, part of a recent CNN special on trauma care in Iraq,1 succinctly illustrates the need for clear communication between caregivers and patients – specifically, the need to communicate on the patient's level. [See chart listing common ED medical terms and "lay" alternatives]
To address this issue, The Joint Commission has published a policy white paper, "'What Did the Doctor Say?:' Improving Health Literacy to Protect Patient Safety," available at: www.jointcommission.org. The paper offers several specific recommendations, including several that are pertinent to providers of emergency care:
Providers must be patient-centered in their language, asserts Ron Davis, MD, who chaired The Joint Commission expert round table that developed the white paper and who is president-elect of the American Medical Association. "For example, we often refer to people by their medical problem or the organ that is not working very well, i.e., 'There's a laceration in cubicle 3,' or, 'I'm going to see the sprained ankle.'" ED staff, he says, must treat people as people. "Patients overhear you talking like this, and it's dehumanizing and disrespectful," he says.
In terms of clear communications, Davis recommends that ED providers:
Easy as '1, 2, 3'
Davis points out a particularly useful tool mentioned in the white paper: "Ask Me 3" (www.askme3.org). "This refers to three questions that you should always encourage patients to understand and answer back: 'What is my main problem? What do I need to do? Why is it important for me to do this?'" he says. "If the patient has answers to these questions, they have a pretty good chance of doing what they need to do."
Some facilities have their staff wear "Ask Me 3" lapel pins as a reminder and a conversation starter, he says, while others have posters that say, "Make sure you get answers to the following questions. "It's definitely a good idea to have bilingual posters," Davis adds."
The ED at Akron (OH) General Medical Center uses Ask Me 3, reports Susan Clark, RN, MBA, director of nursing/patient services and ED manager. "We are driven to teach patients and family to ask those three specific questions and have done quite a bit of education with staff," she reports. That education includes computerized graphic presentations and role-playing, says Clark. "We then ask ourselves if the communication was handled at a level that the 'patient' understood and whether they could say the answers back to you," she says.
In triage, this teach-back approach is much more effective than simply asking the patient a more general question such as, "Is everything clear?" says Davis. "Patients sometimes just nod their heads because they don't want to feel stupid," he says.
Ahead of the curve
Akron General already has implemented a number of the white paper's recommendations, says Clark. "We jumped on [communication] early, knowing it would be part of the National Patient Safety Goals," she explains, adding that she and her staff suspected that the 2008 National Patient Safety Goals "will be pushing literacy and the AskMe3 program."
In addition to the Ask Me 3 program, her ED has "always done a version of teach-back," Clark says. For example, in crutch training, the staff members actually walk on crutches, show the patient how to handle certain maneuvers, and then have the patient repeat what was demonstrated. The ED's discharge instructions are patient-friendly and have been tested for a fifth-grade reading level.
"We also have several videos we offer for ED and in-house patients for different literacy and language levels, which are available on our TV video system," says Clark. The ED gets the videos from a hospital library of 200-300 tapes contributed by the patient education department, nursing staff development education, and medical education for attending physicians. "They are not necessarily ED-specific, but they are pooled by diagnosis; so for example, if you need to communicate with a patient about a heart problem, you can do so," says Clark. These videos can be dialed from the phone in their room and brought up on the TV screen," she explains. "If need be, the nursing staff can help the patient dial in."
In the near future, adds Clark, the ED will offer a translation service that uses a laptop computer. The program asks the user which language the patient speaks. Once it is selected, the provider types their information in English, and the computer translates it into the native language of the patient. Clark says vendors are being interviewed.
For information about Emergency Department Information Systems, contact:
You can download "AskMe3" posters free of charge, in English or Spanish. Go to: www.askme3.org, and click on "For Providers." Then, click on "Download/Order materials."