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Zeroing-in on Health Literacy: How Enhanced Explanations and Improved Comprehension Can Reduce Patient Anxiety and Fear
| Part of the Influence Factors of Patient Experience inquiry conducted with support from Siemens Healthineers
- We have an opportunity in healthcare to reduce anxiety and fear by providing patients clearer explanations of their diagnosis and treatment.
- We can achieve greater evidence of patient comprehension through communication techniques that ensure their understanding of the care plan./li>
- Collaborative and interactive communication between staff and patients give patients more control over healthcare decision-making, contributing to a better overall patient experience.
Experience Framework Alignment
- Culture and Leadership
- Infrastructure and Governance
- Staff and Provider Engagement
- Quality and Clinical Excellence
About this Case
This Influence Factors case study interview was conducted with Brandon Parkhurst, M.D., Adult Primary Care Service Line Medical Director for Marshfield Clinic Health System (MCHS). As an integrated health system with locations in central, northern, and western Wisconsin, MCHS operates over 50 outpatient facilities with over 10,000 employees including over 1,100 providers in over 80 medical subspecialties. MCHS also manages a health plan and a variety of research and education programs. Via participation in the Centers for Medicare/Medicaid Services (CMS) Physician Demonstration Project, Marshfield Clinic demonstrated skill in improving care quality while reducing the overall cost of care.
What was the opportunity, issue or challenge being addressed?
The main driver of this project at Marshfield was an awareness of communication gaps between staff and patients. This gap was identified through patient comments and survey responses indicating patients were experiencing low levels of comfort during testing and procedures, causing them anxiety and fear. Marshfield believed that through enhanced explanations to patients, anxiety and fear could be reduced when patients achieved a better understanding of their diagnosis and treatment. This focus on health literacy and, more specifically, the use of enhanced explanations to improve patient comprehension, became a top priority to improve the experience for patients of Marshfield by making them feel safer and more comfortable. “Through that focus on explanation and understanding, I think we are seeing a reduction in anxiety and fear that patients would otherwise experience if they didn't understand what was going on,” commented Dr. Parkhurst.
What process was used to develop a solution?
As the former Medical Director of Patient Experience at Marshfield Clinic, Dr. Parkhurst is no stranger to the importance of the patient’s voice in any patient experience improvement effort. “We relied heavily on stories from our patients, perceptions of our patients. We get about 2000 comments every month via our experience surveys. “Those comments shared a wealth of information about how patients not only perceived their care but what they identified as being very helpful to that care,” Dr. Parkhurst shared. In concert with his administrative partner and a handful of patient experience educators, MCHS set out to find possible solutions based on what the patients were telling them. Through discussions with managers and staff, two solutions surfaced to the top. He described the solutions as “pretty standard solutions that were already out there”, namely techniques identified as Ask Me 3 and Teach-Back. Knowing that poor health literacy is a leading root cause of adverse outcomes, MCHS placed effort into training staff on these two techniques as the framework for communication improvement.
What outcomes were you looking to achieve?
Dr. Parkhurst pointed out, “The ultimate outcome we were looking to achieve really was a more collaborative relationship with our patients.” With a greater evidence of patient understanding, he hoped to also impact the broader issues of low health literacy, problems such as unnecessary ER visits, not picking up prescriptions, and the lack of follow-up appointments. He explained that improving health literacy can be achieved through not only a focus on communications but also “just being better partners with our patients in the realm of care they were receiving and the care that we were delivering.”
What specific steps did you take to address the problem?
The steps that we originally took were to create some programming around this. We created a logical story that first identified the impact of health literacy and, second, focused on how common it is for misunderstanding or incomplete information to be present, not just in healthcare but in life in general,” Dr. Parkhurst said. “We shared comments from our patients around techniques that providers and staff have used to impact the patient’s understanding, and we've landed on a handful of techniques that we encouraged staff to utilize moving forward,” he added.
The first technique was to use the communication tool called Ask Me 3, a technique designed to improve patient participation in the treatment plan. It is based on three simple questions that patients should ask their providers in every health care situation: 1) What is my problem? 2) What do I need to do about it? and 3) Why is doing this important to me? Dr. Parkhurst highlighted the connection between these three questions and achieving broader healthcare goals. “We wanted to connect [the answers] back to the bigger question, How does this impact your life overall?” he said. Given the complexity of the healthcare system today, it is not surprising that the care team at Marshfield recognized the distinct relationship between limited patient comprehension and adverse health outcomes. And they made a choice to close that gap.
The second technique used at Marshfield Clinic involved a method called Teach-Back as a means “to establish that our patients were understanding the information that we were sharing in the same way that we did,” shared the doctor. MCHS care teams were encouraged to discuss additional resources that they might use to share information, for example using pictures or other individuals to help provide explanations to patients. He added, “Ask Me 3 and the use of Teach-Back helped make sure that we were on the same page as our patients.”.
What resources, if any, did you engage to address the problem?
Dr. Parkhurst shared that a great resource for him in this project was the family members who were engaged from the beginning. An advocate for including the patient and family voice in all he does, Dr. Parkhurst commented, “When we talk about ‘patients’, it's never just ‘the patient’. It's always family members.” For example, the doctor talked about one of his first endeavors to connect caregivers’ actions and the impact upon others, a grand rounds presentation conducted by him and a MCHS patient experience educator. As participants in the presentation, a patient and his guardian were included, sharing their story and a letter that they had written to Dr. Parkhurst, to share the impact that one of their providers had upon their lives. Specifically, this provider helped them understand what they were supposed to do and why, as the patient walked his path to improvement.
As most in the field of healthcare know, improving patient experience does not have to be complicated or expensive. Sometimes a benefit is realized when others share their thoughts. Dr. Parkhurst acknowledged the other providers at Marshfield who embraced the Ask Me 3 and Teach-Back methods and concluded that an engaged staff is more critical during change than trying to build something new, such as an EMR, which can be very complex and costly. Dr. Parkhurst smiled as he described what he liked the most about this effort, “It was important, and yet it was really pretty simple,” he said.
What measures did you establish to determine the success of this effort?
In speaking with Dr. Parkhurst, he was confident that the techniques they implemented were making a difference in their patients’ eyes. While determining whether the Marshfield staff was successful at reducing fear and anxiety was difficult to ascertain, Dr. Parkhurst proudly acknowledged that the Clinic called out answers to a couple of survey questions that they believed would be a good measuring stick. To verify whether patients were receiving better explanations from Marshfield’s providers and caregivers, they focused on the doctor and nurse communication questions from HCAHPS surveys. Within the few months after the first grand rounds presentation, top box percentages were up by over one point each for both the doctors and nurses for explaining information in ways that were easily comprehended. All indicators pointed to good progress being made in these areas, according to the patient comments.
What was the ultimate outcome of your effort?
Marshfield Clinic is determined to push forward on this project to bring it to ultimate success. They are now initiating a peer-to-peer mentoring process. In lieu of providing an educational component to train on improved patient explanations, Marshfield is choosing to foster conversations amongst peers, How do you do this? How do you approach that? In the beginning, Marshfield will target providers, but Dr. Parkhurst is not limiting the training to just providers. “There's no reason that it would ever need to be limited to just providers and to the [discussions] that happen in the office behind a closed door with a patient. [Great communication] can occur with any member of the care team: hospital, inpatient, or outpatient,” noted Dr. Parkhurst. He added that observing someone else and coaching, ‘Hey, this is what I saw you do that seemed to support understanding, what could we do to support that more?’ will have greater impact than classroom training. Marshfield will initially start the peer mentoring process with their hospitalist groups. “We see this as one of the keys to sustainability and continuous improvement,” he stated.
What lessons would you share with others addressing a similar issue?
experience projects need to be focused to be successful. He remarked, “We have worked for three to four years around improving communication. The conversations went well, but they inevitably ended in the same place. We were too wide [in our goals] to start with.” Dr. Parkhurst’s advice would be to narrow the training field and focus on making a few small changes. “We gained traction when we started to focus on explanations and understanding. We gained more traction when we tied that concept to health literacy, which just happened to resonate with the providers and staff in this organization,” he added.
As most know in healthcare, the impact of health literacy is well defined. The lack of understanding and the impact of not understanding is something that we can all relate to. Marshfield found a lot of resonance with that tie-in. “We can all agree the everybody needs to know their diagnosis or the symptoms. Everybody needs to know why you're doing this. Everybody needs to know why it's important,” Dr. Parkhurst said reciting the steps of Ask Me 3.
In wrapping up, he restated lessons learned about this project at Marshfield. He emphasized, “Narrow the focus. Find something that resonates with people, something that everybody can connect to.” It is obvious in this project that a focus on health literacy created that connection for the staff at Marshfield. This connection lies at the heart of healthcare and is often the main reason why people go into the field in the first place: to help other human beings. As this case study shows, speaking to others as human beings is fundamental for improved health literacy, allowing patients to take a more active role in their own healthcare decisions and have more control over their patient experience, hopefully one with less anxiety and fear.
For more information contact:
Brandon Parkhurst MD, MBA, CPXP
Medical Director, Adult Primary Care Service Line
Marshfield Clinic Health System