Quality Improvement and Care Management Questions Are the Answer: Getting patients involved in their healthcare Doug Seubert Quality Improvement and Care Management Marshfield Clinic September 9, 2008

Marshfield Clinic Over 40 centers throughout northern, central and western Wisconsin 750+ physicians in 80 medical specialties and subspecialties 361,436 patients served Patients seen from every county in WI, every state in the nation, as well as 25 foreign countries Marshfield Clinic is the largest physician group practice in the state of Wisconsin. We have developed or partnered in a number of initiatives and projects to raise awareness of health literacy within our organization and within the communities we serve. www.marshfieldclinic.org

Family Health Center Family Health Center is a federally qualified community health center that offers primary and preventative care to the residents of an eleven county region in north central Wisconsin. Within this service area FHC targets all individuals living at or below 200% of the federal poverty level who experience access to care barriers. Family Health Center of Marshfield, Inc. partners with Marshfield Clinic to provide primary and preventive care services to underserved populations. These are some of the patients that benefit the most from our health literacy initiatives.

The AHRQ Web site The Agency for Healthcare Research and Quality web site offers resources for consumers and patients. The focus of this presentation is the “Consumers and Patients” resources available through the Agency for Healthcare Research and Quality (AHRQ) website: mainly, “Questions Are the Answer.” www.ahrq.gov

Improving Health Care Quality is a Team Effort “The single most important way you can stay healthy is to be an active member of your own health care team. One way to get high- quality health care is to find and use information and take an active role in all of the decisions made about your care.” AHRQ Web site Health literacy is more than just the ability to understand basic health information. It’s also knowing how to apply that information to make appropriate health decisions. Questions Are the Answer, like all of the AHRQ consumer and patient resources, emphasizes the patient as the most important member of the health care team. This underlying concept supports a patient-centered approach to providing safe, effective healthcare. Health literacy is the key to patient activation. Getting patients involved in their own healthcare begins with improving communication.

Why encourage patients to ask questions? Benefits of Asking Questions Increases understanding Increases patient involvement Improves adherence Improves satisfaction Improves patient-provider communication Demonstrates patient-centered care Builds trust in relationship Consequences of NOT Asking Questions Increases risk for errors Limits information and patient involvement Decreases adherence Decreases satisfaction Increases opportunities for miscommunication Increases confusion and intimidation Heightens unmet needs Why encourage patients to ask questions? There is very little published research to show that interventions that encourage patients to ask questions have an impact on patient outcomes. However, there is evidence to support that even simple interventions increase question asking among patients who would otherwise not ask questions. Use of question prompt sheets and agenda setting tools are often well received and considered useful by most patients; they increase patient satisfaction; and in one study, where patients were offered a list of questions prior to a medical consultation, doctors reported these patients to be taking more initiative and control, especially in subsequent visits. While there is no direct evidence linking “question asking” to improved clinical outcomes, it is not a big leap to suggest that increased patient satisfaction, higher levels of trust, and increased patient involvement lead to better understanding, improved patient adherence, and a decrease in the opportunities for miscommunication and risk of medical errors. Overall, these benefits do impact patient health and outcomes. SOURCES: Katz MG, Jacobson TA, Veledar E, Kripalani S. Patient literacy and question-asking behavior during the medical encounter: a mixedmethods analysis. J Gen Intern Med. 2007 Jun;22(6):782-6. Diette GB, Rand C. The contributing role of health-care communication to health disparities for minority patients with asthma. Chest. 2007 Nov;132(5 Suppl):802S-809S. Gordon HS, Street RL Jr, Sharf BF, Souchek J. Racial differences in doctors’ information-giving and patients’ participation. Cancer. 2006 Sep 15;107(6):1313-20. Street RL Jr, Gordon HS, Ward MM, Krupat E, Kravitz RL. Patient participation in medical consultations: why some patients are more involved than others. Med Care. 2005 Oct;43(10):960-9. Davis RE, Koutantji M, Vincent CA. How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study. Qual Saf Health Care. 2008 Apr;17(2):90-6. Middleton JF, McKinley RK, Gillies CL. Effect of patient completed agenda forms and doctors’ education about the agenda on the outcome of consultations: randomised controlled trial. BMJ. 2006 May 27;332(7552):1238-42. Cunningham C, Newton R. A question sheet to encourage written consultation questions. Qual Health Care. 2000 Mar;9(1):42-6.

Why do errors occur? When medical mistakes occur, it most often results from miscommunication between the physician and patient, according to a nationwide survey of 1,600 physicians. That suggests that, despite the availability of sophisticated, promising medical treatments, basic human interaction is a linchpin in the delivery of effective healthcare. (Published in Health Leaders Media Magazine, August 2008) A recent national survey asked physicians their opinions regarding why medical errors occur. The top reason reported was “miscommunication between physician and patient.” The second most reported reason: “human error on part of caregiver.” Initiatives that improve communication between doctors and their patients, and providing opportunities for patients and their caregivers to ask questions and clarify information may be important in decreasing medical errors. For more information, refer to “Doctors Diagnose Healthcare” published in the August 2008 issue of HealthLeaders Magazine. HealthLeaders Media Magazine

Questions Are the Answer The Questions Are the Answer Web site offers great information. You can watch or download a video of the public service announcement. (click “PSA” to view video) There is an interactive tool called Build Your Question List, an extensive list of important questions to ask divided into categories to help patients pick the ones they want to ask. The list of questions can be printed with the page pre-formatted with space to write in the answers. (click “Build Your Question List” to view the question builder tool) The AHRQ Web site also provides printable versions of Questions Are the Answer as posters and brochures. (Click “posters and brochures” to see an example) PSA Build Your Question List Poster and brochure The Questions Are the Answer Web site offers great information including 5 Steps to Safer Health Care, 20 Tips to Prevent Medical Errors, and tips to help patients Be Prepared for Medical Appointments. You can watch or download a video of the public service announcement. (click “PSA” to view video) There is an interactive tool called Build Your Question List, an extensive list of important questions to ask divided into categories to help patients pick the ones they want to ask. The list of questions can be printed with the page pre-formatted with space to write in the answers. (click “Build Your Question List” to view the question builder tool) The AHRQ Web site also provides printable versions of Questions Are the Answer as posters and brochures. (Click “poster and brochures” to see an example) www.ahrq.gov/questionsaretheanswer

Simple Ways to Incorporate Questions Are the Answer Links to AHRQ on organization’s Web site Run PSA (video) on in-house TV channels Order (or download and print) information AHRQ Publications Online Store Display and distribute Incorporate into physician and staff education Simple ways to begin using Questions Are the Answer. Please refer to the copyright and linking requirements posted on the AHRQ Web site). Links to AHRQ on organization’s Web site. Run PSA (video) on in-house TV channels. Order (or download and print) information from the AHRQ Publications Online Store. Display “Questions are the Answer” posters and distribute the brochure to patients. Incorporate “Questions Are the Answer” into physician and staff education. Raising awareness of health literacy among physicians and staff is important. Effective initiatives educate patients and physicians/staff. Of particular importance is recondition physicians and staff not to ask “So, do you have any questions?” but to rather use open ended questions like “So, tell me what questions do you have about taking your medicine?” It’s also important to create an atmosphere where questions are welcomed, where patients are not intimidated to ask questions or feel like they are “bothering” their doctor. Copyright Considerations and Linking to AHRQ Site: Referrals

The Digital Divide Percent of people who NEVER obtain health information from the internet: Proficient 12% Intermediate 14% Basic 58% Below Basic 80% National Assessment of Adult Literacy (2003) In a recent survey of Family Health Center members, 60% reported that they never use the Internet, and another 9% said they rarely use it. This follows data gathered through the National Assessments of Adult Literacy that showed those with below basic literacy rarely use the Internet as a source of information. The way to reach patients who would most benefit from health literacy initiatives, then, is not through the Internet. The information and tools are out there, but health care providers/organizations need to find ways to make this information accessible to those who do not use the Internet. In a recent survey of Family Health Center members, 60% reported that they never use the Internet, and another 9% said they rarely use it. The way to reach patients who would most benefit from health literacy initiatives, then, is not through the Internet. The information and tools are out there, but health care providers/organizations need to find ways to make this information accessible to those who do not use the Internet. N=1668, FHC Member Survey (2008)

Beyond the Internet Newsletters and mailings Appointment reminders provide link for more information provide option to mail “hard copy” on request 1-800-931-AHRQ (2477) Appointment reminders letters and phone calls Agenda setting “be prepared for medical appointments” posters/tear-offs in waiting and exam rooms Examples of how to bring information and tools from the AHRQ Website to patients who might not have Internet access. Newsletters and mailings: The patient consumer information available on the AHRQ Web site is copyright free and can be reprinted. Refer to the copy considerations posted on the AHRQ Web site. When reprinting information in newsletters and patient handouts, provide a link to the AHRQ Web site for more information. For those patients who do not use the Internet, provide an option to request a “hard copy” mailed to them. Either provide the toll-free number to the AHRQ publication clearinghouse (1-800-931-AHRQ) or provide your organization’s number for patients to call and request a copy of the information. This works particular well for booklets. Appointment reminders: Develop messages that can be automatically printed on appointment reminders. For example, if patients are told to bring all of their medications to their appointments, ask patients to also bring along a list of questions to ask their doctor. This statement could also be included in the script for appointment reminders by telephone. Agenda setting: Agenda setting tools help patients prepare for their appointments. This can be something that is mailed with appointment reminders, or it can be something that is handed to the patient when they arrive for their appointment. It also works as a rooming tool. When the patient is roomed and the vitals have been taken, the patient may be waiting a few minutes before the doctor comes in. This is a good time for staff to ask patients to think of any issues they want addressed or questions they want their doctor to answer. I sheet can be provided for patients to write down questions (and later the answers). Handing the patient a copy of the “Questions Are the Answer” brochure to review while waiting for the doctor is another approach. Brochures and posters can be displayed in the waiting areas as well as exam rooms.

A Community Effort Topics include: Health literacy curriculum for adult literacy learners, English language learners, and senior citizens. Partners: Marshfield Clinic Family Health Center Mid-State Technical College Literacy Council Community organizations and social services Topics include: Where to find health care in the community Family history Medication safety Preventive care Talking to your doctor Questions are the answer Marshfield Clinic collaborated in the development of a health literacy curriculum for patients and consumers with low literacy skills. The 16-part curriculum incorporates several AHRQ tools and resources, including: Questions Are the Answer (includes video), how to create a pill card, medicine safety (includes video), communicating with your doctor (includes video). Much of the curriculum uses “hands on” and role play activities. The curriculum was developed to be flexible and adaptable to different audiences. It can be used in classroom setting, broken into small workshops, or used during one-on-one tutoring.

“Questions Are the Answer” in the Curriculum View PSA (video) Discuss importance of asking questions Demonstrate “build your list of questions” Provide copy of the brochure Role play and practice Include asking for clarification, note taking, recording, bringing a family member Depending on the audience, type of presentation, and amount of time, Questions Are the Answer is used in a number of ways: The PSA (video) is played followed by a discussion on the importance of asking questions. The “build your list of questions” tool is demonstrated (if a computer with Internet access is available). Many of the larger classes and workshops are held at the local Technical College with access to a computer lab. A copy of the Questions Are the Answer brochure is reviewed. Workshop attendees can take it home along with the other materials from the workshop or class. Role play exercises were developed for workshop attendees to practice asking questions. The unit also includes: asking for clarification – perhaps the most important question a patient can ask is: “I’m not sure I understand what you want me to do (or how to take this medicine). Can you explain it to me again?” note taking and recording – many patients don’t know that they can take notes, ask for written instructions, or even record them to listen to when they return home. bringing a family member or other care giver – we stress the benefits of bringing a family member or other caregiver to the appointment to help ask questions, remember instructions, or assist with reading handouts and filling out forms.