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Service Delivery Innovation Profile

Program Makes Staff More Sensitive to Health Literacy and Promotes Access to Understandable Health Information

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The Health Literacy Collaborative of UnityPoint Health (previously Iowa Health System) educates staff on the importance of communicating health information clearly to patients and families regardless of reading ability, creates easy-to-understand materials based on patients’ needs and preferences, and trains health care workers to use these materials with their patients. As a result, health care workers are increasingly sensitive to the varied reading skills and learning preferences of their patients, and patients have access to more understandable health information. These improvements, in turn, have been associated with high levels of satisfaction with patient–provider communication.

See Did It Work? for updated results. (Updated August 2014.)

Evidence Rating (What is this?)

Moderate: The evidence consists of pre-implementation and ongoing comparisons of patient satisfaction survey data, tracking process measures, and anecdotal reports of staff sensitivity to and awareness of health literacy issues.
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Developing Organizations

Health Literacy Collaborative of UnityPoint Health
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Date First Implemented

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Patient Population

Vulnerable Populations > Rural populationsend pp

Problem Addressed

Health information directed toward patients is often too technical for most to understand, regardless of educational background, reading level, or level of health literacy. Asking patients their needs and preferences for receiving health information, using plain language principles and teach-back, and creating reader-friendly print materials to meet their needs can aid their understanding.
  • Lack of health literacy a common problem: Ninety million Americans have difficulty understanding and acting on health information.1 The average patient covered by Medicaid reads at a fifth grade level, while the average American reads at an eighth or ninth grade level. Even those who have advanced literacy skills may have trouble reading and understanding complex, specialized medical terminology, especially when ill, faced with difficult choices, and/or are elderly.2
  • Serious implications: When patients do not understand health information, their care may be compromised, leading to increased risk of medical errors and higher health care costs.2

What They Did

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Description of the Innovative Activity

The Health Literacy Collaborative of UnityPoint Health (previously Iowa Health System) works to improve quality and safety by fostering effective communication. Using strategies such as reliable use of teach-back by all nurses, incorporating reader-friendly principles into newly developed written materials, creating a patient- and family-centered environment that welcomes questions, and engaging staff members in group discussions, UnityPoint Health enables patients to read, understand, and act on health information. Key elements of the program include the following:
  • Building system-wide capacity in teach-back: Teach-back involves asking patients to explain in their own words what they hear their providers say, which allows clinicians to assess the accuracy of patients' understanding and correct any misinformation. Training and improvement strategies enable care providers to use teach-back and plain language principles for key communication with patients and families.
  • New and revised information for patients and families: The collaborative encourages teams to create new and revised patient admission forms, consent forms, and disease education materials on a variety of conditions in collaboration with the New Readers of Iowa (an adult learners program), risk managers, health care providers, surgical services staff, and the legal department.
  • Ongoing feedback on materials: The collaborative works with literacy advocacy groups and adult learners, whose feedback is vital to creation of materials that are clear and easy to understand. For example, their feedback was a key component in successful development and adoption of a reader-friendly consent document by most UnityPoint Health senior affiliate hospitals. Patient responses to inquiries about reading comfort and how they prefer to learn health information alert team members to the need to revise existing materials and create materials in new formats that aid patients’ understanding.
  • Empowering patients and families to ask questions: "Ask Me 3" is used as a tool to help patients and families feel comfortable asking questions. With "Ask Me 3", the health care team strives to answer three essential questions during patient encounters: What is my main problem? What do I need to do? Why is it important for me to do this?
  • Ongoing staff education and support: The collaborative engenders awareness and sensitivity to health literacy issues among UnityPoint Health colleagues by raising and addressing health literacy concerns at staff meetings. Additional ongoing opportunities for learning and sharing best practices are provided through team calls; a Web site with resources, links, and opportunities for discussion threads; and continued development of State, regional, and national partnerships.

Context of the Innovation

At the time of this innovation, UnityPoint Health (previously Iowa Health System) included 26 hospitals in metropolitan and rural communities, more than 140 physician clinics, home health groups, and a telephone call center. The impetus for the Health Literacy Collaborative came from the Institute of Medicine (IOM), which identified health literacy as a cross-cutting priority to achieve high quality care, and from a UnityPoint Health staff member who served as part of the Iowa Medical Society team who attended an American Medical Association train-the-trainer workshop on health literacy. In addition, the chief medical officer, who also served as Iowa Medical Society president, championed incorporation of health literacy into the UnityPoint Health clinical performance improvement strategic plan. Simultaneously, UnityPoint Health applied the organization's work with the Institute for Healthcare Improvement (IHI) on patient safety to health literacy by forming a learning collaborative to improve patients’ understanding of health information.

Did It Work?

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The Health Literacy Collaborative has increased staff awareness of the importance of clearly communicating health information to all patients regardless of reading level or level of health literacy and has led to high levels of satisfaction with patient–provider communication.
  • Heightened awareness of literacy issues: Health system leaders and staff report a heightened awareness of patients’ difficulty in understanding standard health information. Since the program's inception, they are more likely to voice the need to consider materials from a health literacy point of view.
  • Improved patient–provider communication: UnityPoint Health uses top box analyses of the Hospital Consumer Assessment of Healthcare Providers and Systems scores for four health literacy–related domains for evaluation: communication with nurses; communication with doctors; communication about medicines; and discharge information. Information provided as of June 30, 2014 indicates the following (efforts are ongoing to continue and maintain improvements):
    • Communication with nurses: Increase from 72.0 percent (baseline in October 2006) to 78.9 percent in the second quarter of 2014. (Updated August 2014.)
    • Communication with doctors: Increase from 76.0 percent (October 2006) to 80.4 percent in the second quarter of 2014. (Updated August 2014.)
    • Communication about medicines: Increase from 58.0 percent (October 2006) to 63.4 percent in the second quarter of 2014. (Updated August 2014.)
    • Discharge information: Increase from 82.0 percent (October 2006) to 88.8 percent in the second quarter of 2014. (Updated August 2014.)

Evidence Rating (What is this?)

Moderate: The evidence consists of pre-implementation and ongoing comparisons of patient satisfaction survey data, tracking process measures, and anecdotal reports of staff sensitivity to and awareness of health literacy issues.

How They Did It

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Planning and Development Process

The planning and development process emphasized teamwork, collaboration, and training.
  • Team formation: The health literacy collaborative includes nurses, staff and patient educators, quality improvement personnel, home health workers, risk managers, surgical services personnel, and members of the health system's legal department. Health literacy team leaders and team members were identified by the senior affiliate hospital leaders. Team leaders usually had expertise in staff and patient education or quality improvement.
  • Collaborating with outside groups: Working with outside groups is essential to producing materials that are understandable to all patients. The collaborative worked with literacy advocacy groups such as the New Readers of Iowa who served as advisers to the collaborative by evaluating and providing feedback on new patient materials. The collaborative also collaborated with external partners such as the Iowa Medical Society, the Iowa Hospital Association, the Iowa Pharmacy Association, the Iowa Department of Public Health, the Iowa Department of Education, and faculty of the Drake University College of Pharmacy.
  • Attending workshops: Collaborative participants attended a variety of learning sessions to discuss ways in which the IHI Model for Improvement, the American Medical Association train-the-trainer module, and the American Medical Association health literacy education toolkit could inform their efforts. Workshop participants received copies of the toolkit, the IOM report, CD-ROMs, and PowerPoint presentations to engage their hospital administrators and staff and identify areas to begin their work. Teams used small tests of change to introduce and spread health literacy interventions.
  • Training programs: The collaborative used 1-day training programs to learn about and develop new and revised health information for patients throughout the system. The workshops also taught participants how to discuss these materials with their patients and ask questions to gauge patient understanding.

Resources Used and Skills Needed

  • Staffing: The collaborative includes nurses, staff and patient educators, quality improvement staff, and home health personnel. Collaborative initiatives are typically integrated into the everyday responsibilities of existing staff members.
  • Costs: Program costs consist primarily of the expenses associated with periodic meetings (there have been 12 over 7 years), health literacy training sessions, and development of materials.
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Funding Sources

Health Resources and Services Administration; Wellmark Foundation; AMA Foundation; UnityPoint Health
The project was supported with internal funds and grants.end fs

Tools and Other Resources

The Iowa Literacy Resource Center.
Available at:

American Medical Association Foundation. Health Literacy.
Available at:

National Center for the Study of Adult Learning and Literacy.
Available at:

Iowa Healthcare Collaborative. Health Literacy.
Available at:

Abrams MA, Earles B. Developing an informed consent process with patient understanding in mind. NC Med J. 2007;68:352-355. [PubMed]

Lorenzen B, Melby CE, Earles B. Using principles of health literacy to enhance the informed consent process. AORN J. 2008;88:23-29. [PubMed]

Miller MJ, Abrams MA, Earles B, et al. Improving patient-provider communication for patients having surgery. Patient perceptions of a revised health literacy-based consent process. J Patient Saf. 2011;7(1):30-8. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Engage leaders in the program: Health system leader support is essential to shifting an organization’s culture to one that places primary importance on patient understanding of health information.
  • Identify an individual or team to serve as program champion: The champion(s) must be passionate about improving communication and patient understanding.
  • Involve patients, families, and adult learners: Include patients, families, and adult learners in telling the story, making the case, and developing interventions to address health literacy.
  • Train staff appropriately: Train staff to discuss with patients their learning preferences and to use teach-back methods to assess understanding.
  • Ensure program integration: Integrate the program throughout the organization, including all points of care (e.g., admission, medications, diagnoses, procedures, recovery, discharge home, and followup care). Begin with small tests of change.
  • Involve physicians: Engage physicians early in the process in practicing teach-back methods and/or in developing easy-to-understand materials. Consider involving them, for example, in improving consent forms, as it is vital to ensure that patients give truly informed consent before any surgery or procedure.
  • Avoid literacy testing of patients: This can undermine efforts to create a shame-free environment and make patients uncomfortable asking questions or acknowledging a lack of understanding.

Sustaining This Innovation

  • Perform ongoing testing: Continue to test changes on a small scale to build experience and support. Then, expand successful pilot tests by building the improvements into normal operating procedures across the entire organization, including all points of care (e.g., admission, pharmacy, diagnostic testing, surgery and other procedures, recovery, discharge, followup care, and home care).
  • Incorporate health literacy concepts wherever possible: Identify opportunities to integrate health literacy into other work of the organization (e.g., quality, safety, and chronic disease initiatives). Include health literacy concepts in job descriptions, new employee orientations, and competency standards for performance evaluation.
  • Continue to develop and test new tools: Develop tools in multiple media formats in response to patient preferences.
  • Use story-telling for motivation: Share patient stories about the challenges they face in understanding health information; these stories can motivate staff to improve and sustain their communication efforts.
  • Solicit feedback: Listen to and act on feedback from partners, including patients, families, adult learners, and members of literacy organizations.

More Information

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Contact the Innovator

Barb Earles, RN, MHA, CPHRM
Director of Risk Management- Law Department
UnityPoint Health
1776 West Lakes Parkway, Suite 400
West Des Moines, IA 50266-8239
Phone: (515) 241-3707

Innovator Disclosures

Ms. Earles has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Institute for Healthcare Improvement. Health and Literacy Working Together Web site. Available at:

A list of additional references may be requested from the program developer.


1 Institute of Medicine. Health literacy: a prescription to end confusion. Washington, DC: Institute of Medicine; 2004.
2 Wilson JF. The crucial link between literacy and health. Ann Intern Med. 2003;139(10):875-8. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 15, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 11, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.