1. STIC (STRATEGIES TO IMPROVE COLONOSCOPY) Welcome to the Education Module for the Implementation Toolkit ST IC strategies to improve colonoscopy

2. PHYSICIANS IN YOUR PRACTICE WANT TO IMPLEMENT EVIDENCE-BASED PRACTICES TO IMPROVE THE QUALITY OF OUTPATIENT COLONOSCOPY Intra-procedure Quality Measures Cecal IntubationAdenoma Detection Pre-procedure Quality Measures Patients’ experienceAdequacy of bowel preparation Evidence-Based Practices Split-dose of bowel preparation Low-literacy educationTeach-back You can get a jumpstart on improving patient care by following the steps in this education module, using the materials provided by the STIC study and by visiting the implementation toolkit website to access tools to help you implement evidence-based-practices to improve bowel preparation for your patients STI C strategies to improve colonoscopy

3. STI C strategies to improve colonoscopy THE STIC TOOLKIT Includes everything you need to implement split- dose bowel preparation, low- literacy education, and teach-back

4. STI C strategies to improve colonoscopy THE STIC TOOLKIT 1. 1. Education Module Step by step guidance to learn about the EBPs and how to use them 2. 2. Website Easy access to tools and resources to help you perform teach-back and provide education for bowel preparation 3. 3. Materials 5 month supply of a 4-page low-literacy education brochure for patients on split-dosing of bowel preparation Tailored to your practice Tailored to your choice of bowel preparation Tailored to the patient’s appointment Poster and pocket cards to remind you about using teach-back

5. Information on evidence-based practices and why we use them Information on Split-Dose Bowel Prep and why it’s recommended Information on Health Literacy and why it’s recommended to use low- literacy materials Information on Teach-Back and why it’s recommended IN THIS EDUCATION MODULE YOU WILL FIND… STI C strategies to improve colonoscopy How to implement these evidence-based practice in your clinical setting Tips and resources to help with implementation

6. LEARN What are evidence-based practices and why do we use them? What is split-dose bowel prep and why do we use it? What is health literacy and why do we use low-literacy materials? What is teach-back and why do we use it? STI C strategies to improve colonoscopy

7. LEARN Evidence-based practices (EBPs) are guided by consensus of professional groups and the best scientific evidence EBPs are available for colon cancer screening and colonoscopies. They include: Guidelines on who should get screened and how often Bowel preparation methods that improve outcomes and the patient’s experience (Split-dose prep is an EBP) Strategies to improve patients’ adherence to their bowel preparation method (Using low-literacy materials and teach- back) What are EBPs? STI C strategies to improve colonoscopy

8. LEARN Why do we use Evidence-Based Practices (EBPs)? EBPs work best for most patients. Using the following EBPs for outpatient colonoscopy can significantly improve patient experience and the quality of bowel cleansing: The split-dose bowel prep method Low-literacy prep instructions Using teach-back to ensure a patient’s understanding of the instructions Improving the adequacy of bowel prep can decrease the need for repeat procedures and ultimately lead to better adenoma detection STI C strategies to improve colonoscopy

9. LEARN Split-dose bowel prep is a method where the patient takes ½ the medication dose the evening before and the other ½ the morning of their colonoscopy Any 4-liter or 2-liter PEG medication or oral NaP can be split In healthy non-constipated individuals, a 2-L PEG formulation produces bowel cleansing quality similar to 4-L PEG_ELS formulation The second dose should begin 4-6 hours before the procedure with completion at least 2 hours before the procedure Split-dose is separate from the laxative that may or may not be use What is split-dose bowel prep (SDBP)? STI C strategies to improve colonoscopy First dose Second dose

10. LEARN Why do we use SDBP? Split-dose of bowel preparation is recommended by gastroenterology societies and approved by the FDA Meta-analysis data from 5 randomized blinded trials show better patient satisfaction and adherence with split-dose. Split-dose leads to higher adenoma detection rates Cecal intubation rates also increase with split-dose prep Split-dose does not significantly increase the number of patients who have to stop to go to the bathroom on the drive to the procedure STI C strategies to improve colonoscopy

11. LEARN Health literacy is the ability to understand and process health information in order to follow instructions for treatment Health literacy is more than just a patient’s literacy level Health literacy is influenced by a patient’s state of mind, education-level, culture and the degree of trust between the patient and the health care provider What is health literacy? STI C strategies to improve colonoscopy Low-Literacy Word Swaps Instead of…Try using… AdequateEnough, the right amount ApproximateAbout, around, near CompleteFinish, end BeverageDrink, fluids, liquids

12. LEARN Why do we use low-literacy materials? Medical care is complicated and many people struggle with understanding how to use medication A RCT found that the odds of adequate bowel preparation increased by 3.7 times (95% CI; 2.3-5.8) for patients who received low-literary education written at a 6 th grade reading level 1 The National Quality Council and Agency for Healthcare Research and Quality recommend that providers assume that everyone may have difficulty understanding instructions for medication use Healthcare practitioners have a duty to provide ALL patients with instructions for bowel preparation that are simple, clear, and in plain language 1. Spiegel, BM. et al. Development and validation of a novel patient educational booklet to enhance colonoscopy preparation. AM J Gastroenterol. 2011; 106:875-883 STI C strategies to improve colonoscopy

13. LEARN Teach-back is one of the most effective evidence-based practices for improving patients’ understanding of written and verbal instructions It involves asking patients to repeat information back in their own words, correcting instructions that were not explained clearly and reinforcing patients’ understanding Teach-back is an indication of how well you taught the bowel preparation instructions, not a test of the patient’s knowledge What is Teach-Back? STI C strategies to improve colonoscopy

14. LEARN Why do we use Teach-Back? 40-80% of the medical information that patients receive is forgotten immediately Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands. Healthcare Practitioner Explains Instructions Recalls and Comprehends Healthcare Practitioner Explains Instructions Recalls and Comprehends Healthcare Practitioner Reassesses Patient Recall and Comprehension New Concept for Patient: Instructions for bowel preparation New Concept for Patient: Instructions for bowel preparation Adherence to bowel preparation instructions Healthcare Practitioner Assesses Patient Recall and Comprehension Healthcare Practitioner Clarifies and Tailors Explanation Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A. Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med/Vol 163, Jan 13, 2003 STI C strategies to improve colonoscopy

15. USE Low-literacy education materials for split-dose bowel prep Step-by-Step instructions for using teach-back with your patients STI C strategies to improve colonoscopy

16. USE The Essentials Start giving your patients this 4-page education brochure on split-dose. The STIC study tailored the brochure to your practice, the patient’s appointment, and the type of prep The STIC study will provide your practice with a 5-month supply of tailored colored brochures You can see these materials on the implementation toolkit website that you can access at the end of this education module Low-literacy Education Materials for Split-Dose STI C strategies to improve colonoscopy

17. USE The Extras An additional 4-pages are available if you want to provide your patients with more information about colonoscopy and how to prepare for their procedure You can download and print these pages from the implementation toolkit website Low-literacy Education Materials for Split-Dose STI C strategies to improve colonoscopy

18. 1.Contact patients by telephone before their colonoscopy 2.Review key points of bowel preparation instructions with your patient 3.Ask patient to repeat back instructions in his or her own words 4.Assess for understanding, review again if necessary 5.Reassess for understanding STEP-BY-STEP INSTRUCTIONS FOR USING TEACH-BACK USE STI C strategies to improve colonoscopy

19. Remember teach-back is a test of how well you taught the bowel preparation instructions. This is not a test of the patient’s knowledge The goal is not for the patient to simply parrot back to you what you said Use teach-back with all patients, not just patients whom you think have low-literacy Use non-shaming, open-ended questions Use plain language USE Key Components for Teach-Back The STIC study will provide you with a poster to hang in your workspace and a pocketcard to help you use Teach-Back STI C strategies to improve colonoscopy STIC.wustl.edu STIC@wustl.edu STIC.wustl.edu STIC@wustl.edu

20. How do I ask patients to repeat back instructions? “I want to be sure that I explained things correctly. Can you tell me how you are going to prepare for your colonoscopy?” “We covered a lot about how to prepare for your colonoscopy and I want to make sure I explained things clearly. What are you going to do to prepare for your colonoscopy?” How do I RE-assess for understanding “I don’t think I explained it clearly to you. Let me try to explain it better.” Things NOT to Say “Do you understand what you’re supposed to do?” “Do you have any questions?” These are yes/no questions and do not give the patient the chance to teach the instructions back to you. What to do if a patient cannot teach back after several attempts Over the phone… – Schedule another opportunity to call and explain – Ask another member of the health care team to explain the instructions to the patient USE Tips for using Teach-Back STI C strategies to improve colonoscopy

21. CONGRATULATIONS! YOU COMPLETED THE EDUCATION MODULE! CONTINUE TO EXPLORE THE IMPLEMENTATION TOOLKIT WEBSITE AND ACCESS TOOLS TO HELP YOU IMPROVE PATIENT CARE