Teach Back as an Effective Patient Education Tool

by Edward Leigh, MA

A patient tells you they understand everything you said about their treatment plan.  You feel good about this patient visit and are ready to close the meeting.  The patient stated they understood, but did they really?

Problem with “Do you understand?” question

There are serious issues associated with the question, “Do you understand?”  Just because the patient says, “Yes,” does not mean they truly understand.  How can you be sure they understand? Use the powerful “teach back” method.

Teach back is a powerful communication tool to assess a patient’s understanding. After the professional shares new medical information with the patient, the patient is asked to “teach back” what they just heard, verbally or in the form of a demonstration. This allows the professional to correct misunderstandings and provide additional information, if necessary. (In some cases, the patient’s caregiver may be the person “teaching back” the information.)

Factors to consider

If the teach back strategy is not properly set up it could actually backfire leading to a worse patient experience.

Patients may feel you are questioning their intellectual abilities. I have interviewed thousands of patients regarding their experiences with healthcare professionals.  For example, I asked one patient if she was familiar with teach back. She stated she was not familiar with the strategy. She also asked, “Is that for people with learning disabilities?” Upon further discussion, she said if a healthcare professional asked her to repeat back what she heard, she would feel that they think of her as dumb. This example illustrates that the set up to the discussion is critical.  It is vital that patients know the strategy is useful for everyone.

This strategy is not a like a pop quiz you had in school. Don’t simply tell a patient, “Repeat back what I just said!”  This comment will put them on the spot and cause anxiety.  They will feel like a school kid who was just told to clear their desk for an unannounced pop quiz.

To avoid these potential issues, ask the patient certain types of questions. View sample questions in the next section.

Sample of open-ended questions to assess understanding

There are many ways to assess patient understanding via teach back. The questions below provide a friendly and comfortable manner to assess understanding.

Focus on “I” Language. It is important to remember teach back is a way to test our abilities at explaining. In other words, we are actually testing ourselves, not the patients. Using “I” language takes the stress off the patient.

• “I want to be sure I explained everything clearly. Can you explain it back to me so I can be sure I did?”
• “Please show me how you will use the device, so I can be sure I have given you clear instructions.”

Focus on how they would tell other people in their lives.

• “How would you describe your health condition to a friend?”
• “When you get home and your spouse asks about your treatment plan – what will say?”

Possible reasons for patients not being able to teach back

If the patient is not able to repeat back their medical situation this may be an indication the professional needs to rework their teaching approaches. There could be several factors reducing the ability of a patient to teach back.

Excessive use of medical jargon. If patients do not understand what professionals are saying, they will not be able to repeat back what was said to them. Use everyday language.  For example, do not say, “NPO after midnight.” Rather, state, “Do not eat or drink anything after midnight.”

Too much information presented too quickly.  The “chunk & check” strategy is a tool to avoid this scenario. Provide a “chunk” of information and then “check” with the patient for understanding.

Patient anxiety.  Regardless of how skilled the professional is at explaining to the patient their medical situation, if the patient is very tense, the material will not be absorbed.  In this case, use empathy. Mention that you understand their feelings of anxiety.  You may want to engage in brief deep breathing exercises with the patient to help them feel calmer so they are better able to take in the information.  The exhale should be longer to achieve maximum relaxation. For example, inhale on a count of four and exhale on a count of six. A few deep breathes goes a long way!

If the patient was not able to repeat back, do not repeat – re-phrase.

Benefits of teach back

Improves outcomes. According to the Joint Commission, research indicates that the teach back technique is effective, not just for improving patients’ understanding, but also for improving outcomes. For example, patients with diabetes whose physicians assess their comprehension and recall with the teach back technique have significantly better diabetes control than patients whose physicians do not use the technique. (Schillinger D, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.)

Can ultimately save time. Professionals often feel they have no time for the teach back method.  It actually does not take very long to assess a patient’s understanding.  Think of how much time it will take if the patient has to call back or visit again.

Enhances patient safety. If a patient does not understand their medical issue, they are at risk. A patient’s medical situation is not nice-to-know information, it is need-to-know information!

Unity Point Health, Des Moines University and other organizations collaborated to develop an excellent Teach Back Toolkit.  Click on the link for more information on this very helpful toolkit.

http://www.teachbacktraining.org/

After giving it – be sure they get it!

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication. The Center focuses on increasing patient satisfaction, improving compliance and decreasing the risk of medical errors. The Center offers high-impact training, consulting and one-on-one coaching. Edward Leigh’s new book, Engaging Your Patients, is due out in late 2014.  http://www.CommunicatingWithPatients.com or 1-800-677-3256

High Physician Satisfaction Equals High Patient Satisfaction: The Winning Strategies of the Organization, Emergency Medicine Physicians

By Edward Leigh, MA

Research has documented that engaged physicians results in engaged patients.  For example, Dr. Jennifer Haas and her research associates found a positive correlation between physician satisfaction and patient satisfaction.  (Dr. Haas and her colleagues work on this subject was published in the Journal of General Internal Medicine article, “Is the professional satisfaction of general internists associated with patient satisfaction?”) Emergency Medicine Physicians (EMP), a leading provider of emergency medical services, prove that high physician satisfaction translates into high patient satisfaction.  The EMP website states, “As a new emergency medicine physician, you’ll be welcomed like family. We’ll take you under our wings in the ED, and out on the town when your shift is over. We believe our tight-knit culture creates the best patient care—because when you love what you do, it shows.”  And it does show!

When I first visited the EMP website, I knew in a moment that I had to write an article about this organization!  Based on their outstanding services, EMP has won multiple accolades, including Modern Healthcare’s Best Places to Work Award, the Press Ganey Summit Award and Smart Business Magazine’s World Class Customer Service Award.

Here are some highlights of what makes EMP an engaging organization for their physicians.

Fun Factor.  Work should be an enjoyable experience.  When looking at their website, it is obvious that this organization clearly understands that having fun is good business. Who wants to work for a dull company?  The website opens with these words, “Enjoy the ride.”  When physicians enjoy the ride so will patients!  The website also has beach photos and humorous videos. The videos include a contest to see which residency program can come up with the most creative video. The organization is like a friendly neighbor welcoming you to their home.

24/7 support from colleagues.  EMP’s supportive culture encourages collaboration in decision making and clinical diagnosis. All physicians have access to run a case by an on-call senior clinical emergency medicine physician 24/7.

Robust education and development. EMP strongly believes in the value of information.  All new physicians travel to the company headquarters and participate in a two-day orientation. Physicians also have the opportunity to participate in EMP’s Patient Satisfaction Academy and Clinical Efficiency Academy.

Work life balance. To help new EMP doctors become acclimated, they design their first year’s schedule.  Even after the first year, EMP accommodates individual needs and requests to create an emergency medicine schedule that works for each person.  EMP understands the important need to maintain a healthy work life balance.

When it’s suits vs. scrubs, scrubs win.  At EMP, doctors thrive in an organization that’s owned and managed by emergency medicine physicians who understand their needs. The focus is on empowerment, not just employment.

Creating an excellent physician experience is an integral part of EMP’s culture.  It is this key component of their culture that drives their excellent patient experiences.

Emergency Medicine Physicians can be reached at 1-800-828-0898 or http://www.emp.com

(I would like to give a special thanks to EMP’s Chief Medical Officer, Dr. Kevin Klauer, for his help in preparing this article.)

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication. The Center focuses on increasing patient satisfaction, improving compliance and decreasing the risk of medical errors. The Center offers high-impact training, consulting and one-on-one coaching. Edward Leigh’s new book, Engaging Your Patients, is due out in the Spring of 2013. http://www.CommunicatingWithPatients.com or 1-800-677-3256

My Mother’s Recent Emergency Department Experience: Lessons for Learning

My mother, Julia, is part of a clinical trial, which involves monthly infusions.  The clinical trial protocol requires periodic blood work, scans, x-rays, etc.  Last week, the physician leading the clinical trial called me at my office and said that my mother has atrial fibrillation and they will not proceed with the monthly infusion. They also noticed that one of my mother’s legs was red and swollen; they were concerned about a possible blood clot. They suggested calling an ambulance and having my mother taken to the closest Emergency Department (ED). I agreed to this action. They then called the ED to inform them of the atrial fibrillation and possible clot.

I called the ED to mention that my mother is on her way and also told them that before leaving my office I will fax over my mother’s medical history information. I have a two-page summary of my mother’s pertinent medical information (e.g., medications, hospitalizations, allergies, etc.).  I told the ED that my brother and I would be there shortly.

Overall, everyone at the hospital was very friendly. However, there were several parts of the experience that could have been improved. This article is a summary of the issues with suggested changes.

Problems with hand off. When my brother and I arrived at the ED, we went to my mother’s room and the nurse told us that their tests did not find atrial fibrillation and that my mother was going to be discharged now.  I asked about the issue with mom’s leg.  They said, “What issue?” In spite of the fact that the clinical trial physician clearly stated the leg needs to be evaluated for a possible DVT, that information never made it to the ED records.  After discussing the leg issue, my mother was scheduled for an ultrasound.  (As an FYI, the ultrasound revealed no clots.) To avoid these botched communication episodes that could seriously harm patients, professionals should engage in “repeat back.” After the information is shared the receiver must “repeat back” the information to verify accuracy.

No partnership statements.  The relationship between the patient and professional is not about giving orders; it is about forming a partnership. Upon admission to the ED, all patients should be asked, “What would make this an excellent experience for you?” What does great care mean to you?” We need to immediately understand the patients’ needs. If we are to be truly patient centered, we need to understand the needs of the patient.  In order to work as a team, we need to understand the patients’ needs.  Working as partners leads to quality improvement and better clinical outcomes.  Of course, this partnership approach leads to higher patient satisfaction.

Use of medical jargon. The people at the ED did not know I was a healthcare professional. They often used medical jargon that I understood, but what if I was not in the field?  When they scheduled the ultrasound, we were told Mom was being evaluated for a DVT. The abbreviation, DVT, was never explained. This is a serious problem in healthcare — the constant use of medical jargon that patients often do not understand.  This is known as a problem with “health literacy.” (The term literacy could mean problems with reading, however it often refers to the ability to understand the language of medicine.)

No signposting. This is a communication strategy in which people are given an overview of what will take place during their stay.  Streets have posts with signs on them (street names) hence the term “signposting.”  These posts with signs give people direction; that is exactly what we want to do with patients, give them direction.  In other words, tell then what will be coming up in regard to their care. This could as simple as saying, “First we will assign you to a room, run some tests and have you seen by one of our highly-qualified doctors. Based on the results of the tests, we will let you know how long you will be here.”  Patients should also be told that we are here to help you and make your stay as pleasant as possible.  There was one significant fact not revealed to our family that could lead to serious damage with patient satisfaction scores.  After being in the ED for approximately 1 1/2 hours, I asked our nurse, “When do you think my mother will have the ultrasound?” She then smiled as though she was about to laugh!  She said the average time for an ultrasound is 4 1/2 hours, but it could be up to 8 hours! This fact should have immediately been told to us.  (As an FYI, we had the ultrasound done in about 3 hours.)

Lack of hourly rounding.  After my mother was in the ED an hour, I expected someone from the medical center to check in on Mom.  No one came to see how Mom was doing.  Hourly rounding is a critical tool for many reasons.  This process helps prevent potential falls by asking patients if they need anything, such as a trip to the bathroom.  Many patients are seriously injured each year because they have to use the restroom and no one is coming to check on them. They try to get up on their own and sometimes fall.  The rounding also has a psychological benefit in that you are reassuring patients that you are thinking of them and working on their care.

No empathy. Going to an ED is a very stressful experience. During my mother’s time in the ED not one person directly stated an empathic response.  I would have liked to hear at least one person say, “I know it is scary being here. However we are here to help you.”  This comment should often be followed by a partnership statement, such as, “We will work together with you to find out what is going on as soon as we could. We will periodically check on you, but if you ever need anything, please feel free to let us know. We are here for you.”

Directions — don’t just tell, show!  When I arrived at the ED, I asked the person at the front desk what room my Mom was in and they told me. I asked for directions. The directions were very complicated due to ongoing construction. The person at the desk said something to this effect, “Go down this hall, turn right at the first hallway, then make an immediately left, go down the corridor until you get to a desk, then make a slight right, etc. What? Huh?  I then asked, “Could you have someone take me there?”  They agreed. When people ask directions, don’t simply give directions; take them to their requested destination.  This is an excellent customer service tip all hospital staff should incorporate into their work with patients and their family members.

Teach back technique not utilized.  After the ultrasound was completed, we were given discharge instructions.  Being in healthcare, I understood all the directions, however what if I was not in the field? Saying to a patient, “Do you understand?” is not sufficient.  In order to determine if they indeed understand, you must use the communication technique called, “teach back.” Ask the patient to summarize the information you provided. This could be as simple as asking, “Tell me what you will do when you get home.”

In summary, all of the hospital staff members were quite pleasant.  However, there were some very significant problems that could have negatively impacted my mother’s health. Based on a poor hand off, the ED was unaware of the leg issue.  Fortunately, my mother did not have a DVT. But what if she did?  This medical center needs to have staff development training covering communications skills, rounding techniques, educational strategies and customer service. These techniques are more than “bedside manner” tips; rather they are skills to avoid potentially serious medical errors.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!  http://www.CommunicatingWithPatients.com or 1-800-677-3256

Edward Leigh’s new book, Engaging Your Patients, is due out in June 2011!

Houston’s St. Joseph Medical Center offers Innovative Method to Communicate with Non-English Speaking Patients

St. Joseph Medical Center (http://www.sjmctx.com) recently became Houston’s’ first hospital to use a unique translation system.

A special phone is set up with two handsets, one for the patient and one for the professional.  Based on the language requested, a trained medical interpreter is immediately brought on the line to help the patient and professional communicate.

The phone system is produced by CyraCom (http://www.cyracom.com) and offers interpreters specializing in 150 languages.  The trained interpreters are familiar with medical terminology, which is critical when speaking about healthcare topics.

If the language is not immediately obvious, patients review a card attached to the phone that has questions in their language. They can use this card to select their language.

Every patient room at St. Joseph has one of the phones. The sets are also located in the medical records department, triage and the front desk. There are a total of 400 phones throughout the hospital.

In healthcare, clear and concise communication is critical. This innovative tool helps avoid language-related issues to provide the best care to patients.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256