Patient materials are often written above the reading level of most adults. Tool 11 of the Health Literacy Universal Precautions Toolkit ("Design Easy-to-Read Material") provides guidance on ensuring that written patient materials are easy to understand. As part of a pragmatic demonstration of the Toolkit, we examined how four primary care practices implemented Tool 11 and whether written materials improved as a result. We conducted interviews to learn about practices' implementation activities and assessed the readability, understandability, and actionability of patient education materials collected during pre-and postimplementation site visits. Interview data indicated that practices followed many action steps recommended in Tool 11, including training staff, assessing readability, and developing or revising materials, typically focusing on brief documents such as patient letters and information sheets. Many of the revised and newly developed documents had reading levels appropriate for most patients and-in the case of revised documents-better readability than the original materials. In contrast, the readability, understandability, and actionability of lengthier patient education materials were poor and did not improve over the 6-month implementation period. Findings guided revisions to Tool 11 and highlighted the importance of engaging multiple stakeholders in improving the quality of patient materials.Address correspondence to Angela G. Brega, Department of Community and Behavioral Health, Colorado School of Public Health, 13055 East 17th Avenue, Mail Stop F800, Aurora, CO 80045, USA. angela.brega@ucdenver.edu. HHS Public AccessAuthor manuscript J Health Commun. Author manuscript; available in PMC 2016 October 28. Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptHealth literacy plays a critical role in comprehension of written health-related materials. And yet numerous studies show that the reading level of patient materials often exceeds the reading skills of many adults. It is estimated that the average U.S. adult can comprehend text written at the eighthto ninth-grade level (Doak, Doak, & Root, 1996; Institute of Medicine Committee on Health Literacy, 2004; National Work Group on Literacy and Health, 1998), although literacy skills are substantially lower among older and low-income adults (Doak et al., 1996;Kutner, Greenberg, Jin, & Paulsen, 2006;Weiss et al., 1994). In contrast, patient materials are often written at or above the 10th-grade level (Aliu & Chung, 2010;Helitzer, Hollis, Cotner, & Oestreicher, 2009;Kaphingst, Zanfini, & Emmons, 2006;Vallance, Taylor, & Lavallee, 2008;Wallace, Turner, Ballard, Keenum, & Weiss, 2005). These high reading levels, in addition to other features that can make documents difficult to understand (e.g., the use of medical terms), render many patient materials unusable for millions of Americans.The Agency for Healthcare Research and Quality developed the Health Literacy Universal Precautions Toolkit to support primary care practices in thei...

Background Change champions are important for moving new innovations through the phases of initiation, development, and implementation. While research attributes positive healthcare changes to the help of champions, little work provides details on the champion role. Methods Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data from a sample of 8 practices which included field notes of team meetings, interviews, and transcripts of facilitator meetings. Results Our analysis yielded insights into the value of having two discrete types of change champions: 1) those associated with a specific project (project champions) and 2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes improvements. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing. Discussion Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions – both project and organizational change champions – are critical players in supporting both innovation-specific and transformative change efforts.

BACKGROUNDWe examined reports to a primary care, ambulatory, patient safety reporting system to describe types of errors reported and differences between anonymous and confi dential reports.METHODS Applied Strategies for Improving Patient Safety (ASIPS) is a demonstration project designed to collect and analyze medical error reports from clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). A major component of ASIPS is a voluntary patient safety reporting system that accepts reports of errors anonymously or confi dentially. Reports are coded using a multiaxial taxonomy.RESULTS Two years into this project, 33 practices with a total of 475 clinicians and staff have participated in ASIPS. Participants submitted 708 reports during this time (66% using the confi dential reporting form). We successfully followed up on 84% of the confi dential reports of interest within the allotted 10-day time frame. We ended up with 608 relevant, codable reports. Communication problems (70.8%), diagnostic tests (47%), medication problems (35.4%), and both diagnostic tests and medications (13.6%) were the most frequently reported errors. Confi dential reports were signifi cantly more likely than anonymous reports to contain codable data.CONCLUSION A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in primary care settings. Information from confi dential reports appears to be superior to that from anonymous reports and may be more useful in understanding errors and designing interventions to improve patient safety.

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PURPOSEWe investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing selfdirected (SD) practices with model information and resources, without facilitation. METHODSWe conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys. RESULTSAlthough measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.CONCLUSIONS Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture. INTRODUCTIONT o meet the challenges of a reformed health care system, primary care must adopt substantially new models such as the PatientCentered Medical Home (PCMH) and integrate their work within accountable care organizations. [1][2][3][4] The PCMH has emerged as a cornerstone of primary care redesign with its strong appeal of uniting 4 compelling areas of health care reform: (1) the well-demonstrated value of primary care based on 4 core attributes, [5][6] (2) proactive, population-based approaches to chronic care, (3) consumerism and patient-centered care, and (4) new health information technology. Much of the redesign effort has focused on implementing the Chronic Care Model,6,7 which has been associated with better health outcomes for patients with chronic conditions and, specifically, type 2 diabetes 8,9 ; however, data regarding adoption of this model's principles into primary care practices have been disappointing. 10,11 Primary care practices have few mechanisms for incorporating new programs, which can slow adoption of innovations and cause disruptions when innovations are finally implemented. [12][13][14][15][16] With the central importance of primary care in health care redesign models such as the PCMH and accountable care organizations, effective strategies for enhancing primary care practice improvement...

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The Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit was developed to help primary care practices assess and make changes to improve communication with and support for patients. Twelve diverse primary care practices implemented assigned tools over a 6-month period. Qualitative results revealed challenges practices experienced during implementation, including competing demands, bureaucratic hurdles, technological challenges, limited quality improvement experience, and limited leadership support. Practices used the Toolkit flexibly and recognized the efficiencies of implementing tools in tandem and in coordination with other quality improvement initiatives. Practices recommended reducing Toolkit density and making specific refinements.