Assessing Teach-Back Utilization in a Downtown Medical Center.

BACKGROUND: The St. Vincent Charity Medical Center's Patient and Family Education Policy directs staff to provide patients with easy-to-understand written and verbal communication. This includes using plain language and Teach-Back. Teach-Back-or asking patients to explain in their own words what they have learned-is a best practice that health care professionals use to ensure patient understanding. The effective use of plain language is key to using Teach-Back successfully. From random audits, we could assess whether staff were documenting their use of Teach-Back. We had not, however, ascertained whether that documentation was a true account of the use of Teach-Back. Brief description of activity: We created a three-part project to (1) assess staff knowledge and use of Teach-Back, (2) assess and address barriers to use of Teach-Back, and 3) assess patients' recall of their providers using Teach-Back. IMPLEMENTATION: Internal medicine resident physicians (hereafter termed "residents") and nurses completed an anonymous, online survey regarding their experience with Teach-Back. After vetting, these responses were integrated into mandatory provider training. Focusing on health literacy and Teach-Back, the training addressed barriers, reinforced positive experiences, and tailored practice encounters to patients. We then randomly surveyed inpatients to assess their recall of their providers using Teach-Back.
RESULTS: The majority (96.3%) of providers indicated that Teach-Back should be used frequently. Only 79.9%, however, reported using Teach-Back. Providers regarded Teach-Back as important and rated their confidence level as high. Providers also reported barriers to Teach-Back. Of the 135 patients surveyed, 46% recalled their providers using this method. LESSONS LEARNED: We note a gap between providers' self-reported use of Teach-Back and patients' recall of their providers using it. Providers may be overstating their utilization rate. The survey, further, assessed patients at random points in their hospital stays, to include those who had not yet received Teach-Back education. These factors could contribute to the observed discrepancy. Most notably, results confirmed our position that regular provider training helps address barriers and misconceptions about Teach-Back. [HLRP: Health Literacy Research and Practice. 2021;5(3):e226-e232.] Plain Language Summary: Our Health Literacy Institute was created in 2007 after receiving a grant to institutionalize health literacy across the continuum of patient care. Health literacy refers to a person's ability to obtain, understand, and process basic information, which empowers them to make appropriate health decisions.

From then to present, we have recognized Teach-Back as a best practice. And to ensure patient understanding, we have created policies to advance that method, as well as plain language principles. These policies address both patient-provider interactions and patient education materials. Health Literacy Institute (HLI) team members have since trained all clinical staff on how to use plain language and Teach-Back. Although random audits had confirmed that Teach-Back use had been documented, we had not assessed whether that documentation reflected its actual use.

Located in the downtown area of a busy municipality, the St. Vincent Charity Medical Center was the setting of this project. Implemented in three parts, the project sought to determine our facility's Teach-Back utilization rate. We designed the first part to assess staff knowledge and use of Teach-Back to include quantifying providers' self-reported use of and confidence in using this method. Furthermore, we designed the project to assess—and to address—perceived barriers to the use of Teach-Back. Finally, the project aimed to assess whether patients recalled their providers' use of Teach-Back.

Background

The St. Vincent Charity Medical Center's Patient and Family Education Policy directs staff to provide all patients with easy-to-understand written and verbal communication (Komondor, 2019). This policy establishes goals for all clinical staff to adhere to the following:

Use plain language in all written and verbal communication to ensure patients at all health literacy levels understand the information they receive. If it is not possible to use plain language for certain terms, use plain language to explain those terms.

Facilitate patient and family understanding of the patient's health status and health care options. To ensure patient understanding, all staff will use the Teach-Back method during each teaching session.

Address the needs of patients, such as those who are deaf (or hard of hearing), have limited English proficiency, have learning disabilities, or have other health issues that would require alternative teaching methods.

Since introducing health literacy principles to our facility in 2007, we have amended our policy to require Teach-Back when educating all patients. Through the American Medical Association's Train the Trainer program (Weiss, 2007), the interdisciplinary HLI team was trained in HL principles, including the use of Teach-Back. Teach-Back, also called “closing the loop,” is a patient-provider communication method that reinforces and demonstrates patient comprehension (Slater et al., 2017). In a friendly, non-shaming way, patients are asked to explain in their own words their understanding of what they have been taught. It is important that providers present Teach-Back as a test of how well they, the providers, have explained health information; Teach-Back is not a test of patients. This allows errors in communication to be addressed before patients leave the hospital (Kornburger et al., 2013). Caplin and Saunders (2015) advocate for the Teach-Back method to assist all patient populations in understanding health information.

Teach-Back instruction is included in new employee orientation and is reinforced annually for all staff through online competency training. Biannual, in-person provider training includes principles of Teach-Back and involves role-playing scenarios. During role-play, providers use Teach-Back with patients and model best practices for its use. Previous random audits assessed whether staff were documenting the use of Teach-Back; we had not, however, assessed whether that documentation reflected its actual use.

Methods

The project team included members of the HLI and a volunteer and used the Plan-Do-Study-Act format to assess the use of Teach-Back. For part 1, the team developed a survey comprising ten questions. Five of those questions were multiple choice, two asked participants to provide a rating on a scale from 1 to 10, one allowed for multiple responses, and the last two were open-ended (See Survey 1: https://figshare.com/s/68c592ba6800a895c430). The first two questions were designed to identify the participant and to determine if the participant was familiar with the Teach-Back method. The next several questions concerned general knowledge and self-reported use of Teach-Back, followed by two questions asking participants to provide 1 to 10 ratings of the importance of using Teach-Back and their own confidence in using the method. After that, tools from the “Welcome to Always Use Teach-Back! Training Toolkit” (Abrams et al., 2012) were incorporated to reveal which specific health literacy practices were used most of the time. Finally, participants were given the opportunity to provide open-ended responses about barriers to using Teach-Back, as well as their own general opinions. The survey was sent to all nurses and residents and was available online from April 1 to April 28, 2018.

For part 2 of our project, results from the provider survey were compiled to guide competency training for nurses and residents. All nurses were required to attend mandatory, in-person clinical competencies from May 15 to June 15, 2018. Conducted by the Director of the Health Literacy Institute, these 1-hour training sessions were offered to small groups several times per day. Each session provided a brief overview of health literacy, and then focused on Teach-Back, as adapted from the “Welcome to Always Use Teach-Back! Training Tool-kit” (Abrams et al., 2012). The training was used to reinforce the use of Teach-Back and included role-playing exercises tailored to responses from the survey. Barriers identified in the survey were discussed during these sessions, and ways to overcome them were addressed. An unanticipated benefit of these sessions was the opportunity to correct outside issues and misconceptions. On the survey, the nurses acknowledged the problem of using interpreters for non-English-speaking patients. However, it was not, as first assumed, because the nurses felt they could not use Teach-Back with these patients. Instead, for many of them, the barrier was simply the logistics of accessing the language services by phone and securing the necessary equipment. In addition, the issue of time was addressed by reviewing the “chunk and check” tool (Agency for Healthcare Research and Quality, 2015), reminding nurses to share small amounts of information at a time, and to then check for understanding.

Two separate and sequential mandatory trainings for residents were completed between July 6 and July 16, 2018. The first training emphasized the importance of health literacy and reinforced the use of tools like plain language and the Teach-Back method. The Director of the Health Literacy Institute delivered a 1-hour, educational presentation. The training, further, included video testimonials of patients, demonstrating how low levels of HL affect patient outcomes. The review of patient cases clearly evidenced the benefits of using Teach-Back. Cases reviewed included those in which patients did not know how to take medications as prescribed, which orders or directions to follow, or about the need for follow-up.

The second one-hour training incorporated interactive plain language exercises and role-play using Teach-Back. Using the Health Literacy Thesaurus (Centers for Disease Control and Prevention, 2009), residents reviewed commonly used medical terms and translated them into phrases that promoted patient health literacy. This was followed by several role-playing examples (created by the Director of the HLI), in which residents played the role of the physician not using Teach-Back. Finally, residents paired up and practiced scenarios in which Teach-Back was used correctly to ensure clear and easy-to-understand communication with patients.

For part 3 of our project, the team created a survey to assess patient recall of their providers' use of Teach-Back. The first step was ensuring compliance with medical center regulations. When asked, the Institutional Review Board acknowledged that in-coming patients sign a consent form—one that permits patient surveys and feedback requests. As such, patients would not need to consent to this project, specifically. This survey, therefore, was not subject to review or validation. Participation was voluntary, and patients were not compensated. Protected health information was not recorded in the paper-based survey. The age and gender of patients were kept separately, for later inclusion in patient demographics.

The patient survey began in the month after the provider training. To ensure valid results, the nature of the project was concealed from providers. The team focused on inpatients on the medical-surgical, adult nursing floors under the care of internal medicine resident physicians and supervising attending internal medicine physicians. Nurses, aids, and therapists also care for these patients.

To ensure a random sample, the project team used randomizer.org—first to select 1 of the 3 medical-surgical, adult nursing floors, and then to select 10 patients from the selected floor to participate. They repeated this process each day of the survey. By survey's end, we had chosen 200 English-speaking patients among the three medical-surgical, adult nursing floors. Of the 200 patients selected, 135 patients agreed to participate.

The project team appointed a non-clinical volunteer to administer the patient survey. The volunteer worked under two primary directives: do not interfere with patient care and conceal project activity from all providers. The survey ran Monday through Friday from August 6 to August 31, 2018. During this 20-day period, from approximately 9:30 a.m. until 1:30 p.m., the volunteer met with each of the 135 participants individually. Although the visits were contingent upon patient availability, the volunteer aimed to survey 10 patients each day. For each patient interview, the volunteer confirmed the patient's willingness to answer a few questions. With that consent secured, the volunteer asked the survey questions, writing down the patient's verbal response to each. Interviews took less than 10 minutes to complete.

The survey itself consisted of 5 questions (See Survey 2: https://figshare.com/s/bdeb4dba5725ffa99be9). The first question asked if patients had talked with a health care team member about their medications and health concerns. If patients responded in the affirmative, they were prompted to identify the staff member with whom they had spoken. Then, to assess whether Teach-Back had been used, patients were asked if their provider had asked them to explain back—in their own words—what they had learned. Moreover, patients were asked to recall the information they had learned from that provider. Finally, patients were asked whether they thought talking about their health with someone from the health care team was helpful.

Results

The provider survey yielded 244 responses from nurses and residents. Respondents included 90% nurses, 3% postgraduate year-1 (PGY-1), 3% PGY-2, and 4% PGY-3. At 98%, the majority of respondents acknowledged familiarity with Teach-Back, and 95% were able to correctly define the term. Most respondents (>95%) stated Teach-Back should be used always or frequently, but a lesser majority (70%) acknowledged using Teach-Back with their patients. In addition, >90% of respondents felt Teach-Back was very important and professed high confidence in using it.

The provider survey also asked about key components of effective Teach-Back. The respondents were asked to select which elements they used more than one-half the time within the past work week (Figure ). For this question, participants were allowed to select multiple answers. Use of plain language ranked highest, followed by use of a caring tone and comfortable body language. The survey's last two questions allowed for open-ended responses. The most common barriers to use of Teach-Back included patient disinterest, patient's mental state, language barriers, and lack of time (Figure ).

Self-reported use of Teach-Back.

Barriers to the use of Teach-Back.

As mentioned, providers attended education sessions that reinforced Teach-Back and health literacy policies. One month after that, 200 patients from the medical-surgical, adult nursing floors were randomly selected for a survey. Of those selected, 68% agreed to participate. The average age of participants was 61.41 years. Approximately 90% of patients acknowledged that someone from the health care team (98% of whom were residents and nurses) had taught them about issues related to their medical conditions. Then patients were asked if their health care providers had asked them to use their own words to explain what they had learned. Only 46% of patients said “yes” (Table ).

Finally, patients were asked what they had learned about their medical conditions. Although the focus of our project was to determine the extent to which patients recalled use of Teach-Back, the survey included other topics they could recall, as well. The number of responses relating to a medical condition, medication, or instruction was tallied for each survey. The average number of responses that were medically relevant to the patient (as opposed to answers about the hospital) was 1.02, with the highest responses being 5. Some patients confirmed that they had been asked to use their own words to explain their conditions. For these patients, an independent t-test was used to determine if they were able to give more medically relevant responses on the survey. Patients who answered “yes” averaged 1.14 medically relevant responses versus 0.94 with a p value of 0.264. The increase in the number of topics recalled by those who were taught with Teach-Back was 0.2 more than those who were educated without it (Table ).

Lessons Learned

Our facility's health literacy policies require that plain language and Teach-Back are used for all patients. This project sought to reinforce the use of Teach-Back for both nurses and resident physicians, highlighting it as a best practice for ensuring patient understanding. It measured self-reported use of, and opinions about, Teach-Back, and then assessed whether patients were aware of, and benefited from, the method. The results from this improvement project show that nurses and residents are familiar with Teach-Back and have a favorable view of this method. Additionally, providers felt that Teach-Back is important for ensuring patient understanding, and they feel confident in their ability to use the method. However, a gap seems to exist between the frequency with which providers reported using Teach-Back and the frequency with which patients reported its use. Either providers are overstating how often they use Teach-Back, or the survey was given before patients had received any education. We could also be seeing a combination of both.

Most respondents to the provider survey provided positive feedback regarding Teach-Back, but some negative opinions were expressed as well. “Takes too long” and “patient dependent” were more common criticisms of the Teach-Back method. In practice however, Teach-Back does not appreciably require more time, and it allows patients to provide responses that help providers assess patient understanding. Using Teach-Back takes approximately 1 to 2 minutes more per session when used appropriately (Bodenheimer, 2018). This point was emphasized in the nurse and resident training to demonstrate how effective Teach-Back can save time in the long-term care of patients. Criticism that Teach-Back is patient-dependent is likely associated with the extent to which patients are able or willing to receive any form of instruction. It may be true that some patients are not able to grasp information during their illness or may not be willing to participate in meaningful ways. These conditions may necessitate using Teach-Back with a family member or with some other patient-designated person.

To ensure all patients understand the information provided to them, the Teach-Back method is most efficient. Health Literacy Universal Precautions, a toolkit developed by the Agency for Healthcare Research and Quality (2015), is a series of steps health professionals can use to ensure all patients understand information important for their health. Review of these principles and feedback from residents and nurses during training sessions confirmed our position that regular provider training helps address barriers and misconceptions about Teach-Back.

Project results reveal several weaknesses. First, neither the provider survey nor the reinforcement training included therapists, counselors, attending physicians, surgeons, or other members of the health care team. Future improvement projects can address this concern to ensure that everyone who provides patient services is participating in Teach-Back and using plain language. The use of Teach-Back with family members and other patient-designated people could also be improved upon. Second, the patient surveys did not exclude respondents who had not yet been educated. These patients would skew the results of our project, showing less of an effect than a project that examined patients after discharge. Depending on the length of hospital confinement, many patients receive Teach-Back education toward the end of their stays, when they are stable and more likely receptive to instruction.

The patient survey was administered at random points during patients' hospital stays—including to those who were not well enough to experience any form of education. This possibly accounts for the number of patients who reported not receiving Teach-Back. A non-clinical volunteer conducted the surveys and concealed project activity from providers. This was necessary to ensure that staff members would be unaware of Teach-Back being studied in our facility. This strengthened the results by preventing bias of providers who, knowing about the project, may have (even unwittingly) exaggerated their Teach-Back interactions.

The project did not investigate what patients were taught. The amount of education and the number of topics were not fully measured. This only underscores the challenge of measuring the effect of a method such as Teach-Back. Teach-Back needs further study to evaluate patient recall more accurately once patients have left the hospital.

Several patients, instead of addressing what they had learned about their health, responded with compliments toward the staff and the facility. The question was intentionally phrased to not lead respondents to talk specifically about their health. Instead, the question sought to determine how often patients would report learning medically relevant information without being primed to offer that as a response. A validated survey for assessing Teach-Back post-discharge would be a great tool for a future project and could potentially serve as a standardized basis for surveying patients.

On average, patients who were surveyed were able to recall at least one medically relevant teaching point. Patients who were asked to use their own words to describe what they learned had higher averages of recalled medical information than those who did not report use of Teach-Back. This information suggests that Teach-Back may be associated with higher patient retention of health information.

An unforeseen benefit of the project was the opportunity to remedy any misconceptions providers had about Teach-Back. As mentioned, one misconception was that Teach-Back consumed too much time. We were able to disprove this concern during the provider training sessions. Further, this method of providing teaching sessions after self-reported surveys may be replicated in those organizations wishing to eliminate certain barriers. These training sessions also proved useful in reaffirming the Teach-Back method as a best practice.

When surveyed, 79% of providers reported using Teach-Back; only 46% of patients surveyed, however, recalled this method being used. Factors that may have influenced these results included patient demographics and the timing of the survey. Patients were chosen at random times during their stays and, therefore, may have been surveyed shortly after admission and before receiving patient teaching. We need further studies to assess the use of Teach-Back with patients before they are discharged, as well as after discharge. Finally, the study would benefit from assessing patients' recall of their own medical information and instructions after those patients have been discharged.

Table 1

Patient Survey Results (N = 135)

Characteristic/Question	Variables
	M (SD)		Range
Age	61.41 (15.95)		20–98 years
Sex
Female	n = 84		62.50%
Male	n = 51		37.50%
People interviewed	Yes	No	Incomplete
	135	63	2
Have you talked about your medical problems with a member of the health team?	Yes	No	Do not remember
	123	11	1
If someone has talked with you, do you remember who they were?	Doctor, Nurse, Other Medical Personnel	Both
	52	63
	Doctor, Nurse, Other Medical Personnel	Do Not Remember
	11	2
Did they ask you to explain back in your own words what you learned?	Yes	No	Do not know	No response
	59	62	8	6
Was talking with a member of the health team about your health helpful?	Yes	No	Do not know	No response
	114	12	5	4
Medically relevant responses (opposed to answers about other non-health topics)	M (SD)		Minimum	Maximum
	1.02 (1)		0	5

Table 2

Patient Recall Analysis[a]

Teach-Back Reported	95% CI	Teach-Back Not Reported	95% CI
1.14	[0.85, 1.43]	0.94	[0.74, 1.14]

Note. Calculated using independent t-test. CI = confidence interval.

Medically relevant topics verbalized. p value = .264.