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Executive Summary

Communication is one of the foundations of health care. Every health care interaction depends on effective communication, from making an appointment and registering for a visit to describing symptoms, discussing risks and benefits of treatments, and understanding care instructions. Good communication is linked to improved patient satisfaction, adherence to medical recommendations, and health outcomes.

Today, many health care professionals believe that communication is more effective when it is patient-centered, or responsive to a patient's needs, values, and preferences. While patient-centered communication is often described only in terms of individual clinician-patient interactions, hospitals and health systems can encourage patient-centered communication. It is especially important that hospitals and health systems use patient-centered strategies to reach populations that may not receive or understand standard communications. These include patients with limited or no English proficiency, limited health literacy, or cultural backgrounds that are not well understood by hospital or health system staff.

The Ethical Force Program and the Health Research and Educational Trust conducted eight hospital site visits to learn about patient-centered strategies being used to improve communication with vulnerable patients. Hospitals were selected by a national expert advisory panel based on several criteria, including location, patient diversity, creativity of strategies, and their potential for use at other organizations. Interviews and focus groups with hospital/health system leaders and staff addressed three main topics: 1) organizational factors that led them to develop initiatives to improve patient-centered communication; 2) what they thought every U.S. hospital or health system should be doing to improve patient-centered communication; and 3) lessons learned from their efforts.

Several recurring themes emerged from these discussions, presented in the report as "promising practices." Hospital and health system leaders can use these practices as starting points to encourage patient-centered communication in their own organizations.

PROMISING PRACTICE #1
Encourage Passionate Champions Throughout the Organization
The eight hospitals are committed to communicating effectively with vulnerable populations. This was demonstrated through leaders' support for innovative communication initiatives, and through managers and clinical staff's passion for initiating and sustaining them. In particular, managers and staff were confident that communication initiatives would succeed because their hospitals:

• Make leadership support visible. Hospital leaders saw effective, patient-centered communication as a requirement for providing high-quality care and achieving their hospitals' missions.
• Integrate communication initiatives. Successful communication initiatives do not stand alone. The initiatives were well integrated into the hospitals' preexisting activities.
• Start small. Successful communication initiatives, even large ones, start out small. Once a small program proves that it meets a specific need, it can grow in response to demand.

PROMISING PRACTICE #2
Collect Information to Demonstrate Needs
New communication initiatives are more likely to succeed if the leaders and staff members who implement them can see how they meet specific needs. In some cases patients' communication needs are obvious, in other cases they may be harder to recognize. Hospitals that design and implement communication initiatives are most successful when they:

• Assess the needs of both patients and staff. Each of the eight hospitals has methods for assessing the communication needs of individual patients, patient communities, and staff members. These methods complement written surveys.
• Use data to build support. Hospital champions build support for new communication initiatives by presenting qualitative and quantitative data on communication needs and hospital performance.
• Collect information on model programs. Hospitals rarely develop effective communication initiatives entirely from scratch. Most send representatives to sites that have successful programs in place or consult published guides for instructions.

PROMISING PRACTICE #3
Engage Communities
Each of the eight hospitals has strong ties to its community. These relationships help to keep the hospitals informed of changing patient populations and communication needs. Reliable communication channels also provide opportunities for both sides to share resources and information. Hospitals encourage communities to become engaged when they:

• Work closely with a community advisory board. Most hospitals have a community advisory board or another body that includes community members.
• Collaborate with community organizations. Community organizations are important partners for health education programs. They can help to raise awareness about local health care services.
• Partner on specific programs. Hospitals draw on the experiences and resources in the community by working with them to develop training programs, research projects, and outreach activities.

PROMISING PRACTICE #4
Develop Workforce Diversity and Communication Skills
The eight hospitals believe that health outcomes improve when patients are able to communicate about their health and feel respected by hospital staff. For this reason, each hospital makes it a point to hire staff members who reflect and understand the racial, ethnic, cultural, and other diverse aspects of their patient populations. The hospitals also make communication training accessible and relevant to their staff members. Specifically, the eight hospitals:

• Recruit and retain diverse staff. To find qualified candidates who can communicate with diverse populations, hospitals partner with local education institutions and take advantage of community hiring events and resources.
• Train staff. Generally, all staff members who interact with patients receive communication training. The training might explore strategies for communicating with respect, working with interpreters, or using the "teach back" method.
• Watch for communication problems. Hospital staff help each other to improve their communication strategies and are encouraged to document problems.

PROMISING PRACTICE #5
Involve Patients Every Step of the Way
Every hospital has strategies for involving patients in their own care and using them as resources for improving care. Often, patients offer unique perspectives on the clarity and relevance of hospital documents and communication programs. Hospital staff noted that they get tremendous return on investment when they:

• Educate patients. Getting patients involved in their own care means talking to them in ways they can understand and providing information that is relevant to their lifestyles and family situations.
• Use patients' experiences. Hospitals can learn from the questions patients ask and the feedback they provide.

PROMISING PRACTICE #6
Be Aware of Cultural Diversity
Most of the eight hospitals serve diverse patient populations. As a result, leaders understand that cultural background can have a strong influence on how patients approach health care and respond to health care information. Cross-cultural communication is most effective when hospitals:

• Recognize the importance of culture. Many of the staff members at the eight hospitals believe there is no such thing as cultural "competence." Instead, they have adopted an attitude of continuous learning.
• Create a welcoming environment. Staff note that patients are more willing to communicate if they are comfortable in the hospital.
• Use interpreters' strengths. Hospitals often benefit when their interpreters conduct outreach into the community, assist patients with health system navigation, and facilitate discussions across cultures.

PROMISING PRACTICE #7
Provide Effective Language Assistance Services
While interpretation and translation services can be costly, the eight hospitals believe that failing to provide these services can cost even more. For example, the hospitals have found that using qualified interpreters means they provide better-quality care, order fewer unnecessary tests, and quite likely decrease medical errors and the potential for lawsuits. To provide the highest-quality language assistance services, these hospitals:

• Coordinate interpretation and translation services. Hospitals that provide language assistance services often have a department to house these services and always have a dedicated staff person to manage them.
• Assess and train interpreters. The hospitals that provide professional staff interpreters require that these interpreters undergo training and are regularly assessed on their language and interpretation skills.
• Assess and train bilingual staff. Bilingual staff are assessed, and often trained, before they are allowed to provide services in a particular language.

PROMISING PRACTICE #8
Be Aware of Low Health Literacy and Use Clear Language
Limited health literacy skills are more common in some populations than others, but many patients have difficulty understanding complex or unfamiliar health information. This is true among English-speaking and non-English-speaking patients alike. Several hospitals focus specifically on communicating with patients with limited health literacy. Staff members strive to communicate in clear and simple language, avoid jargon, and watch for signs of patient misunderstanding. In particular, these hospitals have learned to:

• Carefully review documents, educational materials, and signs. Several of the hospitals are working to make documents, forms, and educational materials clearer.
• Incorporate "teach back" into processes. Some hospitals are building the "teach back" method into their processes. In this process, which has been recommended by the National Quality Forum, health providers ask patients to recount information and instructions they have been given.

PROMISING PRACTICE #9
Evaluate Organizational Performance Over Time
All hospitals have budget limitations and have to demonstrate the value of initiatives.

To prove that a communication effort has valuable outcomes and deserves ongoing or increased funding, hospitals conduct regular performance assessments. These include staff evaluations, interviews, surveys, grievance reviews, focus groups, and other tools. To track and improve communication performance, the hospitals are working to:

• Report and track communication problems. Several hospitals encourage staff members to document communication problems.
• Link communication performance to outcome indicators. Most hospitals are developing strategies for tracking the communication performance of staff and interpreters and linking performance to cost savings.

Also available is a communication consensus report from the AMA's Ethical Force Program, Improving Communication–Improving Care.