Topic: Quality Improvement vs Health Literacy
Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.
A core and foundational part of moving from fee-for-service to value-based care, reducing healthcare costs, and reducing medical errors, is the idea that patients can become active players in their own care. That includes the self-management that goes hand in hand with “architecting” a healthy lifestyle, reducing health risks, and accessing healthcare services in a selective and judicious manner. It also implies that the average, or at least many, healthcare consumers will play an active role in medical decisions, and be partners with their (many) providers in order to prioritize and select the goals and components of their care plan.
A key assumption in achieving this activated patient role, is that the person has a high degree of health literacy – that they understand the concepts, are familiar with the terrain, and can speak the language of healthcare. They will know what HbA1c, BP, Resting Heart Rate, BMI, HDL, LDL, Triglycerides, etc are, what they mean, where they stand on each, and what they need to do about them.
It is by no means clear that we are anywhere near having most people in a position where the terminology is familiar, where they understand the implications, and where they have clear health goals prioritized to lead them to the healthiest life that they can afford, are willing to maintain, and is feasible given their history, health status, and environment.
In fact, Health.gov paints a fairly dismal picture:
Only 12 percent of adults have Proficient health literacy, according to the National Assessment of Adult Literacy. In other words, nearly nine out of ten adults may lack the skills needed to manage their health and prevent disease. Fourteen percent of adults (30 million people) have Below Basic health literacy. These adults were more likely to report their health as poor (42 percent) and are more likely to lack health insurance (28 percent) than adults with Proficient health literacy.6
Health.gov describes health literacy dependencies and implications thus:
Health literacy is dependent on individual and systemic factors:
- Communication skills of lay persons and professionals
- Lay and professional knowledge of health topics
- Demands of the healthcare and public health systems
- Demands of the situation/context
Health literacy affects people’s ability to:
- Navigate the healthcare system, including filling out complex forms and locating providers and services
- Share personal information, such as health history, with providers
- Engage in self-care and chronic-disease management
- Understand mathematical concepts such as probability and risk
Low health literacy can result in many sub-optimal outcomes, including reduced ability to comply with treatment plans, poorer healthcare choices, and ineffective or expensive utilization.
Low literacy has been linked to poor health outcomes such as higher rates of hospitalization and less frequent use of preventive services (see Fact Sheet: Health Literacy and Health Outcomes). Both of these outcomes are associated with higher healthcare costs.
Educational materials from Leapfrog:
Articles from Physician’s Weekly:
- Use of Health Literacy Tools Can Promote Shared Decision Making
- The Impact of Poor Health Literacy in Patients with COPD
- The Effect of Health Literacy on Asthma Control
We will take a QI approach, and discuss the topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat. Unlike most Ishikawa diagrams we have used in past chats, Healthcare Literacy feeds itself – Low health literacy causes continued low literacy, while high health literacy can cause greater health literacy.
Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:
- Policies: office, organization, or national policies, including MU, HIPAA, etc
- Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
- Insurance Models, payer systems
- Vendor policies and processes
- Home visit support
- Machines (equipment, EHR)
- Medical or office equipment
- Home equipment specific to the patient condition
- Integration/interoperation with other office or medical systems, or user personal health records
- Medication dispensing systems
- Personal Health Record and encounter ploanning systems
- Staffing: sufficient and qualified staff
- Training: base training, ongoing training, CME, and patient or carer training
- Attitudes: staff attitudes to technology, adoption vs resistance
- Fatigue (especially alert fatigue)
- Friends and family
- Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
- Supplies: medical or office, inferior fax paper,
- Data: ability to securely share with correct patient, specialist, lab, etc
- Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
- Drug information sheets
- Self-care guides
- Internet sources
- Health outcomes
- KPIs: operational metrics required by practice, local government, state, federal
- Quality and safety metrics
- Targets: set by practice, insurer, etc. as well as patient goals
- Monitoring of home-care
- Adverse Effects reporting
- Home monitoring
- Noise: distracting noises, sound levels too high, etc. due to computer systems
- Space: Cramped, uncomfortable work space etc.
- Time: Too little time per patient or order, too little time in a day, too many demands
- Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.
- What METHODS increase or reduce Health Literacy
- What MACHINE factors increase or reduce Health Literacy
- What PEOPLE issues increase or reduce Health Literacy
- What MATERIALS increase or reduce the risk of Health Literacy
- What MEASUREMENT factors increase or reduce Health Literacy
- What ENVIRONMENTAL factors increase or reduce Health Literacy
MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.
To quote the IHI on what the Triple Aim encompasses:
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
- Improving the patient experience of care (including quality and satisfaction);
- Improving the health of populations; and
- Reducing the per capita cost of health care.
The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.
The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.