By Wayne Neal, BSN, MAT, RN-BC, FCN
Solid patient education strategies are foundational to improved compliance and success with national patient engagement initiatives. Numerous regulatory requirements—Meaningful Use, Value-Based Purchasing, and the Hospital Readmissions Reduction Program—converge to advance the accountable care movement. To succeed in the risk-bearing reimbursement landscape, providers must ensure that patients understand and comply with their care plans.
Like many integrated health systems, Children’s National Health System (CNHS) faces the challenge of implementing patient education initiatives that will produce the desired outcomes across a wide range of patient populations and socio-economic backgrounds. Couple those challenges with statistics from the Institute of Medicine (IOM) revealing that more than half of American adults (90 million people) have some level of limited health literacy (Nielsen-Bohlman, Panzer & Kindig, 2004), and the need for programs that successfully overcome barriers to successful patient engagement is clear.
As a pediatric-focused healthcare organization, CNHS must also comply with patient education requirements laid out by the Centers for Medicare and Medicaid Services and The Joint Commission (2007). To that end, the organization has approached patient and family education as a high priority. CNHS has established innovative system-wide programs that leverage technology, governance, and standardization of processes to ensure patients receive the best education resources—and most important, comprehend the information presented. The end result is that families are more empowered and satisfied with their children’s care plans.
Over the past two years, CNHS has further advanced patient education by establishing the Road to Home program, using technology to integrate a standardized approach to patient education with clinician workflows. Designed to correspond to specific diagnoses or procedures, this initiative ensures that all staff are approaching patient education the same way, and patients are receiving information based on best practices.
Understanding the Challenge
Based in Washington, DC, Children’s National Hospital is Magnet® designated and consistently ranked among the top pediatric hospitals by U.S. News and World Report. The health system is home to the Children’s Research Institute and the Sheikh Zayed Institute for Pediatric Surgical Innovation and encompasses a well-established community pediatric network.
CNHS serves both inner city and suburban areas, encompassing a population that is primarily Caucasian, African-American, and Hispanic and includes a wide array of socio-economic backgrounds. The health system’s international program means that the population served includes a growing number of non-English speaking patients and their families. Its adolescent programs require an expanded patient and family education focus compared to younger populations.
The diversity of CNHS’s patients makes selecting appropriate resources challenging. In addition to IOM statistics regarding limited health literacy, the U.S. Census Bureau recently reported (Ryan, 2013) that the number of people in the U.S. who speak a language other than English has grown by 158% over the last three decades.
Consider the following real-life scenario. A child diagnosed with seizures is admitted to Children’s National. Because his mother speaks a foreign language with an uncommon dialect, communicating with her regarding the child’s medications is challenging. Materials are provided based on her language needs, but it is later determined that she is unable to comprehend the materials due to illiteracy. Over time, the child presents to the hospital multiple times because the mother does not know how to properly administer the medications. After consulting with the mother’s older son, the patient and family education staff at CNHS identify the need for an individualized program that includes a color-coded medication chart with pictures identifying the time of day for administration.
The best resources and formats for patient education are critical to improving outcomes and reducing the “revolving door effect” in healthcare. Even under the best circumstances, health systems like CNHS have to be proactive and creative in their deliver and individualize care based on specific patient needs.
A Best-Practice Approach to Patient Education
CNHS’s patient education initiatives incorporate a number of elements that ensure a successful and comprehensive approach:
CNHS has made patient education a priority by allocating high-level resources to the program. Managed by graduate-level professionals with backgrounds in nursing and education, the organization has made provisions for both family/patient and ongoing staff education.
All new nursing staff must complete a patient education simulation that introduces them to the complexities associated with health literacy and teaching principles, choosing appropriate education resources, and the role of anxiety and unfamiliarity in educating families. Specifically, simulations are conducted in real-life situations using real parents and families of diverse backgrounds.
Patient Education – Best Practice Recommendations
Following a needs assessment and review of patient/family evaluations, CNHS determined a more standardized approach to patient education was needed to address fragmentation and more formalized processes. The outcome of that effort was the deployment of the Road to Home program, a pre-defined education process that provides step-by-step guidance to clinicians and family members.
Nursing staff developed and consulted with other healthcare team members to determine critical components for family and patient education, and families were included in the final review process. Once approved, standardized education tactics based on diagnosis or procedure were integrated into the electronic health record, providing a step-by-step teaching guide for nurses that includes access to pre-defined resources to use with patients and families as well as proven education methodologies.
As part of its standardized approach, clinicians engage and evaluate patients and families via industry best practices using the teach-back method. Through teach-back, patients provide an explanation of what they have learned, providing assurance to clinicians that comprehension has been achieved or indicating that some concepts need reinforcement. Teach-back also includes return demonstration of a skill or procedure and discussion.
The teaching process is enhanced through this standardized approach. Nurses are more aware of what a previous staff member has taught a patient, so information is consistent and complete.
Laying the best technological foundation meant not only addressing the need for content based on the latest evidence but also providing a wide array of formats for presenting information—from paper-based literature to a variety of digital formats. Drug reference, clinical decision support, and patient education resources can be accessed easily from a variety of devices to support streamlined workflows. Tools in the form of video, education carts, tablets, an interactive patient TV system, and smartphones were also made available to support presentation needs.
Specifically, the hospital leveraged its comprehensive drug information and patient education resource provided through Wolters Kluwer Clinical Drug Information to create standard packets as part of the Road to Home program. The content includes leaflets on everything ranging from adult and pediatric medications, conditions, and procedures to the use of natural products and discharge instructions. Nearly 20 languages are supported, and a variety of delivery options make access to the content easy for clinicians.
To address a wide spectrum of patient populations, CNHS needed patient education resources that could be identified as “consumer-level content,” addressing not only limited health literacy but also a broad array of foreign languages—a requirement expected to become a focal point of national regulatory initiatives. Also critical to ongoing success with patient education was a method for keeping content up-to-date. As industry facts, evidence, and best practices quickly become outdated, CNHS required a strategy for regular monitoring of content to ensure delivery of the latest information.
To address limited health literacy, resources are based on industry recommendations that materials be written on a 5th to 7th grade level, using simple sentence structures and short, bulleted statements for easy reading. Other key considerations for engaging patients effectively include age-appropriate illustrations and large-print materials for the visually impaired. Alongside written content, the organization also offers education resources in a variety of digital formats.
Outcomes and Recommendations
As an organization committed to effective patient and family education programs, CNHS has matured the delivery of its strategies to a level well ahead of the industry curve. Patient education initiatives are aligned with industry movements towards standardization, creating a best practice model for success within the accountable care movement.
To date, CNHS has standardized patient education for more than 10 diagnoses and procedures, covering such areas as hematology/oncology, prematurity, anticoagulation therapy, tracheostomy, and others. The organization continuously identifies and evaluates the need for additional program topics based on volume and urgency.
By empowering patients in their care through a complementary strategy that engages technology, workflows, standardization, and governance, CNHS maintains consistently high patient-satisfaction scores on the Press Ganey survey question that asks if nurses informed using clear language for both inpatient and outpatient environments. For fiscal year 2014, CNHS’s score improved by 1.9%, positioning CNHS well for the regulatory future.
Wayne Neal is the patient/family education manager at Children’s National Health System in Washington, DC. She may be contacted at WNEAL@childrensnational.org.
The Joint Commission. (2007). The Joint Commission guide to patient and family education (2nd ed.). Oakbrook Terrace, IL: Author.
Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.). (2004). Health literacy: A prescription to end confusion. Washington, DC: National Academies Press. Retrieved from http://www.iom.edu/Reports/ 2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx
Ryan, C. (2013, August). Language use in the United States: 2011. [American Community Survey Reports]. U.S. Census Bureau. Retrieved from http://www.census.gov/prod/2013pubs/acs-22.pdf