Overview
Frequently, practices are unaware of how hard patients find reading and completing forms, understanding health information, and navigating the healthcare system. Patients are in the best position to help you identify areas for health literacy improvement.
Action
Use multiple ways of gathering patient feedback.
Shadow patients.
- Have someone (like a nurse or patient educator) quietly observe a patient throughout a visit. Shadowing can provide valuable insight into how a patient experiences your practice. The presentation Navigating the Health Care System describes the kinds of information you can obtain by shadowing a patient.
- Decide how many patients to shadow and the timeframe within which you would like to complete the shadowing.
- Select diverse patients to shadow who represent the range of patients your practice sees. Consider age, gender identity, race, ethnicity, language, and health issues. A mix of new patients and patients who have been with your practice for years is ideal.
- Before their appointments, tell selected patients about your goal of improving patients' experiences in the practice and ask if an observer can go along with them during the visit. Be aware that not all patients will want to be observed.
- When shadowing patients:
- Stay with them from the time they arrive until they leave. Try to arrange to meet new patients outside your building to see how easy it is to find your practice’s entrance and check-in desk.
- At the end of the visit, ask the patient what went well and what was difficult about the visit.
- Complete a Communication Observation Form after each visit observed. This form focuses on the quality of communication with the patient. You can add questions to the form to address other topics your practice is interested in.
Conduct a walk through.
- Have a person unfamiliar with the practice walk through it with a staff member and give feedback on the signage and the physical environment.
- Be sure that anyone who conducts a walk through will not observe any private or confidential interactions.
- Consider recruiting a student from a local adult education program to conduct a walk through.
Observe patients using your patient portal.
- If you have a patient portal, ask several patients if you may observe while they use the portal. Try to include patients who are not very experienced using computers.
- Watch patients log in. Ask what they would do if they forgot their user id or password to make sure instructions on the home page are clear.
- After you let them explore the portal, ask them to complete a specific task (e.g., find information on a particular topic, look up their lab results, request a prescription refill), and ask them to describe what they are doing. Observing how patients use the portal will help you know where changes in appearance, wording, organization, or navigation of the portal may be needed.
- The Patient Portal Feedback Form contains a list of questions you can ask to gather feedback from patients about their experience using the portal.
- Discuss the feedback you collect with your patient portal vendor, and explore ways to address problems patients are experiencing.
Engage patient and family advisors.
- Having patient and family advisors (PFAs) provides opportunities to:
- Learn from patients and families.
- Get feedback on patient education materials.
- Receive input on policies that affect patients and families.
- Connect with the community you serve.
- Integrate patient and family perspectives into improvement teams.
- Larger practices may want to establish a standing patient and family advisory council (PFAC). Having virtual and hybrid meetings may help you recruit and retain diverse members.
- You can find information on recruiting and working with PFAs and forming a PFAC from the.
TIPS: Getting feedback on materials
Find out what patients think of your materials by asking neutral, open-ended questions, such as:
- "What do you think the key points are?"
- "Which parts are easy to understand and which parts are hard to understand?"
- "What questions do you have after reading/watching this?"
- "What, if anything, would you do anything differently after reading/watching this?"
- "What was helpful and what was not helpful?"
- "Does it seem friendly and supportive?"
- "Is there anything offensive?"
- "Do you have any other reactions you would like to share?"
You can also get patient feedback using other methods, such as asking them to "think aloud" while reading or watching the material or asking them to demonstrate how to follow the instructions in the material.
Have a suggestion box.
- Let patients and family know you want to hear about any difficulties they have understanding information they have been given or getting the help they need. Use this poster to encourage patients to suggest ways your practice can improve.
Survey your patients.
- Conduct quick, informal surveys to help you asses your health literacy improvement efforts. Learn more about the Plan-Do-Study-Act (PDSA) method to refine the changes you make in Tool 2: Assess Organizational Health Literacy and Create an Improvement Plan. You can also use data your practice already collects from formal patient experience surveys, such as the CAHPS® Clinician & Group Survey.
- Choose survey questions. Chose a few questions that will supply feedback on the changes you are planning or have made. Keep surveys short. Sources of questions include the following.
- The Health Literacy Patient Feedback Questions contains questions on spoken and written communication, self-management support, and other supportive systems. Note that these questions were designed to collect information informally for quality improvement work on tools in this Toolkit and are not validated.
- The CAHPS health literacy and interpreter services questions were designed to be used with the CAHPS Clinician & Group Survey. Learn more about the CAHPS Health Literacy Item Sets for Addressing Health.
- Choose which patients to survey. Your goal is to get feedback from diverse patients in terms of demographics and health conditions.
- Make sure that the patients you ask to complete the survey are able to observe and report on changes you have made. For example, if you have implemented action planning only with patients with certain conditions, you will want to survey patients who have those conditions.
- You can use a convenience sample of patients instead of choosing patients randomly. Be aware that a convenience sample will not be representative of your patient population. You can add a few demographic questions to your survey to check that your sample is diverse. Pursue responses from patient populations that are not represented.
- Choose how many patients to survey. Small samples can give you quick feedback as you refine improvements. The larger the number of patients who respond to your survey, the more confident you can be in the results. If you want more reliable information, try to obtain 50 completed surveys.
- Choose how to administer the survey. Surveys can be conducted in-person, by phone, on the web, or by mail. There are pros and cons to each approach.
- In-person surveys are convenient. Check-in staff can ask each patient if they would be interested in providing feedback to improve care. If they say yes, ask patients to complete the survey at the end of their visit, before they leave.
- Be aware there will be bias in your sample. In addition to having more people who make frequent visits, your sample will probably include fewer patients with Medicaid or Medicare, patients who are Black, and patients with incomes below $25,000, since .
- Having someone ask the questions rather than filling out a paper makes participating easier for patients with limited literacy skills. However, patients may be concerned about providing negative feedback to staff they know. Try to identify a volunteer from outside the practice who can collect survey data. Talking tablets is another option.
- Phone surveys can reach a more representative sample of patients, but because few people respond to phone surveys there may be other biases. Phone surveys overcome literacy barriers and are sometimes used as a followup to a mail survey.
- Mail surveys are less expensive than phone surveys but typically have lower response rates.
- Use a plain language cover letter to introduce and explain the purpose of the survey.
- Web-based surveys can make it easier to collect and analyze data but are less likely to get responses from people who do not use computers much.
- Consider providing an audio option to address literacy barriers.
- Using your patient portal to survey patients creates a bias, since are more likely to be younger, white, privately insured, and have a higher income than patients who do not use portals.
- Give patients a choice and assure confidentiality. Regardless of how you collect data:
- Make it clear that whether a patient provides feedback or not is their choice, and their care will not change if they say no.
- Let patients know that their responses will remain private—their providers will not see their responses or even know that they completed the survey.
Act on your results.
- Bring aggregated results back to the Health Literacy Team.
- Devise a system for ensuring that patients' individual responses are not linked to them in an identifiable way, and only aggregate results are shared.
- Identify areas for improvement.
- Use Tool 2: Assess Organizational Health Literacy and Create an Improvement Plan to identify tools that can address areas identified for improvement. Plan, implement, and test changes to see if they addressed the concerns identified.
- Collect patient feedback as a routine part of your quality improvement activities. Obtaining patient feedback is not a one-time activity; it should be done on a routine basis. Consider obtaining feedback from a sample of patients every quarter.
Track Your Progress
The Health Literacy Team should examine efforts to obtain patient feedback. Ask yourselves:
- Have you carried out plans to obtain patient feedback? For example, were you able to shadow the number of patients you wanted to, and did you complete the process in your allotted time?
- Have you used multiple methods to obtain patient feedback?
- Have you obtained feedback from a sample of patients who are of varying ages, racial/ethnic/language groups, health conditions, and genders?
- Have you identified improvement goals based on feedback?
- Have you implemented improvement plans?