Joint Commission warns on consent, literacy
The informed consent process is a linchpin of health care risk management, but even the most earnest efforts to fully detail the risks of treatment can be for naught if the patient simply can't understand what you're saying or what is written.
A new report from The Joint Commission says that is exactly what happens in many cases: The health care provider is trying to inform the patient, but the information just isn't getting through. The same thing happens in other key discussions, such as when explaining aftercare or medication use.
Whether the communication is oral or written, there sometimes is no real information exchange because the patient cannot understand medical jargon and unclear language. The Joint Commission recently released its newest public policy white paper, "'What Did the Doctor Say?:' Improving Health Literacy to Protect Patient Safety." The paper frames the existing communications gap between patients and caregivers as a series of challenges involving literacy, language, and culture, and suggests multiple steps that need to be taken to narrow or even close this gap.
Most risk managers know that written communications, such as the informed consent documents, can pose a challenge for patients with low literacy, and health care organizations have taken steps in recent years to simplify written communications or provide other assistance, such as explaining the documents verbally. But The Joint Commission is warning that low literacy also can affect comprehension during a spoken conversation. Addressing low literacy in the spoken conversation can be even more difficult, the group says, because it is difficult to determine if the patient really comprehends.
Patient safety threatened
Dennis S. O'Leary, MD, president of The Joint Commission, says the disconnect between highly educated clinicians and their patients can threaten patient safety. "If patients lack basic understanding of their conditions and the whats and whys of the treatments prescribed, therapeutic goals can never be realized, and patients may instead be placed in harm's way," he says. And of course, that lack of understanding means an increased liability risk as well.
Even patients who can read and write may be unable to understand much of what is conveyed to them during the informed consent process, says Sunil Kripalani, MD, MSc, assistant professor in the Division of General Medicine at the Emory University School of Medicine and internist at Grady Memorial Hospital, both in Atlanta.
"The average adult in the United States reads at the eighth-grade level," Kripalani says. "National studies have shown that, while only 1% of the U.S. population is illiterate, about 45% have difficulty reading and comprehending moderately difficult information like they find in the health care setting."
90 million adults at risk
A patient who is literate isn't necessarily health literate. Kripalani explains that health literacy is an individual's ability to read, understand, and act on health information. Kripalani notes that according to 2006 results of the National Assessment of Adult Literacy conducted by the U.S. Department of Education, more than 90 million adults lack the literacy skills needed to effectively function in the health care environment.
Low health literacy is associated with less medical knowledge, infrequent receipt of preventive services, increased hospitalization and use of emergency care, and worse control of chronic diseases. Kripalani's research has determined that some simple strategies, such as asking patients to repeat information back to the doctor or nurse, can help address low health literacy.
The Joint Commission called together a panel of experts to discuss the problem, and they offered detailed suggestions for making effective communications a priority in protecting the safety of patients. Failure to provide patients with information about their care in ways that they can understand will continue to undermine other efforts to improve patient safety, they said.
The Joint Commission already promotes the involvement of patients in their care through its ongoing Speak Up educational campaigns. In addition, expectations regarding patient engagement and involvement in care decisions are stipulated in Joint Commission accreditation standards and its National Patient Safety Goals.
The Joint Commission report on strategies for addressing health literacy and protecting patient safety contains 35 specific recommendations that cover a wide range of important improvement opportunities. Examples include the use of established patient communication methods such as "teach back" and the provision of medical liability insurance discounts for physicians who apply patient-centered communication techniques.
A complete copy of The Joint Commission white paper, "'What Did the Doctor Say?:' Improving Health Literacy to Protect Patient Safety" is available at www.jointcommission.org. The link to the report is on the home page.
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For more information on health literacy, contact:
- Sunil Kripalani, MD, Msc, Grady Memorial Hospital, GMH, Department of General Medicine, 69 Jessie Hill Jr. Drive, Atlanta, GA 30303. Tele-phone: (404) 727-5640. E-mail:skripal@emory.edu.