Digital Repository Doctoral Projects Spring 2023 Reducing Health Literacy Disparities of Outpatient Procedure Patients Misty Hastings Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Hastings, M. (2023). Reducing Health Literacy Disparities of Outpatient Procedure Patients. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. WSU REPOSITORY MSN/DNP Reducing Health Literacy Disparities of Outpatient Procedure Patients Project Title by Misty Hastings Student’s Name A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT March 13, 2023 Date Misty Hastings, DNP, CRNA Student Name, Credentials April 28, 2023 (electronic signature) Graduation Date DNP, MSN/Ed RN, CNE, COI DNP Project Faculty Name, Credentials (electronic signature) DNP, APRN, CPNP-PC, CNE Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Note: The program director must submit this form and paper. March 13, 2023 Date March 13, 2013 Graduate Programs Director REDUCING HEALTH LITERACY DISPARITIES 2 Abstract Non-compliance with preprocedural instructions is a common issue affecting surgical departments nationwide (Hostetler, 2020). This issue can lead to adverse effects for the patient and the facility where the procedure is scheduled (Koh et al., 2021). Purpose: This project aims to reduce health literacy disparities of outpatient procedure patients. One element for neglecting instruction compliance is low health literacy levels (Hersh et al., 2015). Unfortunately, healthcare providers' communications with their patients can be above the patients' comprehension level. Educating medical providers about low health literacy and its consequences in the perioperative setting can help to increase patients’ understanding of preprocedural instructions (Davis, 2015). Methods: An educational presentation regarding health literacy was given to the Advanced Practice Providers working at the Endoscopy Center of Western New York. The provider’s knowledge was surveyed both prior to and following the presentation for comparison, and a follow-up questionnaire was utilized to evaluate personal practice changes resulting from the education. Results: This collaboration resulted in an 83% increase in the providers' understanding of health literacy limitations (Table 1). The project was shown to reduce the delays and cancellations seen in the outpatient center by 30% and 35.7%, respectively (Table 3), according to quarterly reports. Practice Implications: Practicing with health literacy limitations in mind can ensure fewer communication inequalities between patients and providers. The project's findings support a gap in medical providers' awareness of this issue, and that education can impact patients' understanding of the instructions provided. REDUCING HEALTH LITERACY DISPARITIES Keywords: Health literacy, medical non-compliance, reduced understanding of preprocedural instructions, anesthesia, preoperative instructions, anesthesia practice guidelines. 3 REDUCING HEALTH LITERACY DISPARITIES 4 Table of Contents Reducing Health Literacy Disparities of Outpatient Procedure Patients ........................................ 6 Background and Problem Statement ........................................................................................... 6 Diversity of Population and Project Site and Benefits................................................................ 7 Significance for Practice Reflective of Role-Specific Leadership ............................................. 7 Literature Review............................................................................................................................ 8 Search Methods and Discussion ................................................................................................. 8 Synthesis of the Literature .......................................................................................................... 8 Complications of Non-compliance ......................................................................................... 9 Policies and Standards .......................................................................................................... 10 Reducing Non-compliance of Procedural Instructions ......................................................... 11 Implications for Practice ........................................................................................................... 11 Framework and Project Application ............................................................................................. 11 Framework Description ............................................................................................................ 12 Framework Application to Project ............................................................................................ 12 Project Plan ................................................................................................................................... 12 Project Design ........................................................................................................................... 13 Needs Assessment/Gap Analysis of Project Site and Population ............................................. 13 Cost Analysis and Sustainability of Project .............................................................................. 13 Project Outcomes ...................................................................................................................... 14 Consent Procedures and Ethical Considerations....................................................................... 14 Instruments to Measure Intervention Effectiveness .................................................................. 14 Project Implementation ................................................................................................................. 14 Interventions ............................................................................................................................. 15 Project Timeline ........................................................................................................................ 15 Project Evaluation ......................................................................................................................... 16 Data Maintenance/Security ....................................................................................................... 16 Data Collection and Analysis.................................................................................................... 16 Table 3 ...................................................................................................................................... 18 Findings .................................................................................................................................... 19 Strengths ............................................................................................................................... 19 Weaknesses ........................................................................................................................... 19 Quality Improvement Discussion ................................................................................................. 20 Translation of Evidence into Practice ....................................................................................... 20 REDUCING HEALTH LITERACY DISPARITIES 5 Implications for Practice and Future Scholarship ..................................................................... 20 Sustainability......................................................................................................................... 20 Dissemination ....................................................................................................................... 21 Conclusion ................................................................................................................................ 21 References ..................................................................................................................................... 22 Appendix A ................................................................................................................................... 25 Appendix B ................................................................................................................................... 27 Appendix C ................................................................................................................................... 31 Appendix D ................................................................................................................................... 33 Appendix E ................................................................................................................................... 34 Appendix F.................................................................................................................................... 35 REDUCING HEALTH LITERACY DISPARITIES 6 Reducing Health Literacy Disparities of Outpatient Procedure Patients Health literacy is defined as the ability of a patient to comprehend medical information (Nutbeam et al., 2017). It has been shown that the non-healthcare population understands medical guidance at a fifth-grade level, while most healthcare information is provided at that of a high schooler (Hersh et al., 2015). When patients do not comply with preoperative instructions, it can result in procedure delays, cancellations, or increased risks during the perioperative period (Desta et al., 2018). Non-compliance with preoperative instructions is a persistent issue commonly seen in outpatient facilities. A study conducted in 2006 highlighted that well over 20% of procedure cancellations were the result of noncompliance with the preprocedural instructions by the patients and, more importantly, that over half of those procedures cancellations could have been prevented by an increased understanding of the instructions provided (Hostetler, 2020). Perioperative risks resulting from patients not following preprocedural instructions can include complications such as vital sign instability, pulmonary aspiration, and a prolonged recovery room stay. In addition, postponing getting a procedure completed may also impact receiving a medical diagnosis and treatments or interventions that could be time-sensitive. This project will reduce the disparities in healthcare practices that can result in misunderstandings of both verbal and written information provided to patients about their medical procedures. By utilizing lay terms and concise and simple instructions, the goal is to improve patient’s understanding of and, therefore, compliance with preprocedural instructions provided to them. Background and Problem Statement Healthcare literacy limitations are a widespread issue within the healthcare arena. Many medical providers are unaware of healthcare literacy's role in patients' compliance with healthcare advice and instructions (National Institutes of Health, 2015). Patients with a lower health literacy level have been shown to have reduced compliance with medications and education provided to them, increased medical complications, and a higher chance of avoiding routine medical care altogether (National Institutes of Health, 2015). While low health literacy is an issue in all medical arenas, the critical focus of this project is outpatient procedure settings. Having patients show up for a medical procedure who have not followed the preprocedural instructions leads to delays and cancellations. As mentioned, non-compliance can be dangerous for patients, leading REDUCING HEALTH LITERACY DISPARITIES 7 to decreased patient satisfaction, scheduling delays for other patients, and loss of revenue for the medical center (Gardener, 2014). Diversity of Population and Project Site and Benefits This project will be implemented at the Endoscopy Center of WNY, a busy outpatient center located in Williamsville, New York. The practice performs routine and diagnostic upper endoscopies and colonoscopies for over 3,000 patients annually (Gastroenterology Associates, 2021a). The patient population at the facility ranges from young adults to nonagenarians. To be a candidate for care at an outpatient facility, these patients must be relatively healthy, with no serious medical comorbidities or life-threatening health concerns (Hostetler, 2020). In addition, the Gastrointestinal center works with many private and government-issued insurance carriers and provides self-pay options for patients (Gastroenterology Associates, 2021b). The patient population seen at the endoscopy center will benefit from this project through an increased understanding of their preprocedural instructions, leading to a reduced risk of having their procedure delayed or canceled. Once a patient’s procedure is canceled, there is a high chance of that patient not rescheduling or being seen by the facility in the future. This avoidance can be detrimental to these patients' health and overall well-being through an increased time for any disease processes to proliferate and a delay in treatment being implemented (Hostetler, 2020). Significance for Practice Reflective of Role-Specific Leadership This project is relevant to my role as an anesthesia provider and doctorate student for the following reasons; as an anesthesia provider, a majority of the preprocedural instructions are related to the pre-anesthetic guidelines put forth to ensure a safe anesthetic can be provided to patients ("Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures," 2017). Increasing the number of patients who follow the instructions will reduce the risk of complications from the anesthetic provided. Another way this project will support my new role as a Nurse Leader is by utilizing the Doctor of Nursing Practice Essential 6: Interprofessional Collaboration for Improving Patient and Population Health Outcomes (Zaccagnini & White, 2015). Collaboration with the Endoscopy Centers' Advanced Practice Providers that see patients in the physician’s offices will improve our patient population's communication and care. Improved communication and care will increase the patient’s understanding of and, therefore, compliance with their preprocedural instructions. REDUCING HEALTH LITERACY DISPARITIES 8 Literature Review This literature review will look at the evidence-based practice standards for preoperative anesthesia directions and the implications of reduced health literacy on compliance with preoperative instructions. Themes emerging from the literature review utilized in the project development included: (a) anesthesia practice standards for nil per os or NPO guidelines, and medication regimens are a mainstay in preoperative instructions ("Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures," 2017); (b) medical information is not provided at the appropriate educational level for a majority of the population (Davis, 2015); and (c) most noncompliance with preprocedural instruction is the result of a lack of understanding (Gardener, 2014). Search Methods and Discussion Search terms for this project included medical non-compliance, health literacy, anesthesia guidelines, preprocedural non-compliance, outpatient cancellations, preprocedural education, NPO guidelines, reduced health literacy, outpatient anesthesia guidelines, preoperative instruction, nonoperating room anesthesia, and aspiration risk factors. Search engines utilized to obtain the literature included CINAHL, EBSCO, Google Scholar, PubMed, and UpToDate. The above-specified terms were used in varying combinations for the literature search. Inclusion criteria consisted of publications available in their complete form, published in English, and spanned between 2012 and 2022. Literature excluded consisted of opinion pieces, dissertations, conference abstracts, and those irrelevant to the current project. Limitations found within the literature review consisted of consistently small sample sizes. For example, the observational study by Singla et al. produced the most participants at 1,050 (2020). These reduced numbers could skew the impact that non-compliance has on same-day procedures. Finding relevant studies that met inclusion criteria specific to outpatient gastrointestinal centers was also challenging. Another practice issue is the evolving literature challenging the current fasting guidelines utilized by anesthesia organizations in the United States, limiting recent studies with the current practice standards. Finally, multiple studies themselves relied on questionnaires completed by the patients, which could lead to altered information depending on the honesty and subjectiveness of answers provided (Kramer, 2000; Singla et al., 2020). Synthesis of the Literature REDUCING HEALTH LITERACY DISPARITIES 9 Patients scheduled for medical procedures requiring anesthesia are provided with written instructions detailing their expectations leading up to their arrival at the operating facility. However, studies conducted by Singla et al. (2020), Arun & Korula (2013), Vetter et al. (2014), and Van de Putte et al. (2019) all found non-compliance with the provided instructions regarding fasting guidelines and medication use present in more than 40% of their respective participants. An observational study assessing the disparities in following the fasting standard showed that 40% of the participants stated a lack of understanding of why they were told to fast (Singla et al., 2020). In comparison, a posttest study provided to garner patients' perceptions of fasting reflected a misunderstanding of the instructions and a lack of the importance of the compliance provided to the patients (Kramer, 2000). Again, these studies highlight the importance of offering simplified instructions at an elementary school comprehension level (Davis, 2015). Collaborative efforts between eleven outpatient procedure facilities to uncover the root of procedure cancellations and how to reduce those numbers found patients not showing up and non-compliance with instructions as two of the top reasons for procedure cancellations (Gardener, 2014). Health literacy has been referenced as a critical factor in misunderstanding and non-compliance with procedural instructions in numerous literary arenas (Koh et al., 2021). Studies have shown that lower health literacy can lead to poorer outcomes and higher medical costs for patients and facilities involved (Desta et al., 2018). Complications of Non-compliance By not adhering to the fasting guidelines provided to them, patients are at an increased risk for pulmonary aspiration, a consequence of having stomach contents breathed into the lungs (Cleaveland clinic, 2021). This can result in serious respiratory complications that could lead to an admission to the hospital for further evaluation and possible airway support (Practice guidelines for preoperative fasting and pharmacological agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures, 2017). Non-compliance with prescription medication adherence is also an area of concern - patients who have abstained from hypertension therapy typically present with uncontrolled blood pressures that do not meet safe parameters. A hypertensive crisis is diagnosed when a systolic blood pressure greater than 180 mmHg or a diastolic reading greater than 110 mmHg is found. These readings can significantly increase a person's risk of suffering a cardiac or neurological event (Gauer, 2017). In addition, uncontrolled hypertension can become an issue when certain anesthesia medications provided to the patient result in vasodilatory effects, which exponentially drop the blood pressure gradient and blunt the body's REDUCING HEALTH LITERACY DISPARITIES 10 vascular reactivity abilities. All of which carry the risk of severe cardiac and neurological impairment concerns for the patient (Colson & Gaudard, 2016). There can also be both personal and financial hardships seen for patients and their families when schedule delays and canceled procedures result from non-compliance (Koh et al., 2021). In addition, most patients must use vacation or sick time from work to have procedures completed and arrange for a family member or friend to be available to transport them to and from the medical facility; this can be hard to duplicate for them (Koh et al., 2021). Patient satisfaction became one of the main focuses in healthcare in 2013 and can have adverse effects on facility reviews, referrals, and finances when not in a facility's favor (Petrullo et al., 2012). While patient satisfaction scores are affected by delaying or postponing a patient’s scheduled procedure, cancellations can, more importantly, delay essential diagnostics needed to initiate medical treatments or required surgical interventions at early stages in the disease course (Gonzalez-Hermoso et al., 2004). The organization is also significantly impacted by reduced or canceled procedures. Losing a scheduled case means a loss in revenue of anywhere from a few hundred dollars to up to several thousand dollars per patient, depending on the type of procedure they were set up to have performed at the center and what medical insurance they possess (Centers for Medicare & Medicaid, 2017). Reducing the facility's revenue while the cost to run the facility remains untouched can be disastrous for any business (S. Shah, personal communication, December 13, 2021). Policies and Standards Many surgical and procedural centers mirror their policies regarding patient requirements to those set forth by the American Association of Anesthesiologists. To meet outpatient procedure criteria, patients must be relatively healthy, free of communicable diseases, and obtain no more than a health classification of three (American Association of Anesthesiologists, 2020). Health conditions found to lead to unsafe risks for outpatient facilities include those with unstable angina, cardiac defibrillators, severe cardiac compromise, end-stage respiratory restrictions or home oxygen use, hemodialysis patients, body mass index greater than fifty, known difficult airway, and end-stage organ disease (Pyne et al., 2021). The standard of practice for preprocedural fasting guidelines that anesthesia providers currently utilize are as follows: clear liquids are to be stopped two hours before any procedure; breast milk is to be stopped four hours before procedures; infant formula, non-human milk, and light meals are to be stopped a minimum of six hours REDUCING HEALTH LITERACY DISPARITIES 11 before any procedure; fried or fatty foods and meat require a minimum of eight hours of fasting (Stecher, 2017), these standards are to be used as a guide, but anesthesia providers are tasked to also use their professional judgment on a case by case basis for safe practices. Reducing Non-compliance of Procedural Instructions The Agency for Healthcare Research and Quality has developed a toolkit that outlines health literacy precautions. These precautions call upon providers to simplify all interactions with patients, ensure their medical environment is patient-friendly, and assist in providing all patients with quality preventative care (Health Literacy Universal Precautions Toolkit, 2020). Patients’ verbal and written communications need to reflect current health literacy guides to reduce non-compliance with procedural instructions. When communicating verbally with patients, healthcare providers must use simple English phrases and avoid medical terms that non-medical people may misunderstand. This could include saying things like high blood pressure versus hypertension or breathing instead of pulmonary or respiratory (Angeles, 2013). The exact process utilized in verbal communication also needs to be applied to all written instructions provided to patients. Over 35% of adult residents in America have a limited understanding of healthcare information which can be a barrier to compliance with medical instructions (Hersh et al., 2015). A randomized control trial conducted at two Veterans Affairs clinics attempted to increase colorectal cancer screening through provider instructions that followed the health literacy suggestions. The results showed a five percent increase in the number of patients who had the screening test completed for the intervention group versus the control group (Ferreira et al., 2005). Other studies have also found correlations between the avoidance of colorectal cancer screenings and low health literacy (Kobayashi et al., 2014; Morris et al., 2013). Implications for Practice As healthcare providers, we all want what is best for our patients. By implementing health literacy practices that will improve patients’ understanding of and compliance with medical instructions, we aim to reduce the delays and cancellations of medical procedures that result from these medical misinterpretations. Educating the Endoscopy Center of Western New York’s Advanced Practice Providers about the implications reduced health literacy can have, as well as techniques and interventions to bridge the gap between what is provided vs. understood, will not only enhance patient satisfaction but will also improve compliance with preprocedural instructions and the overall safety of the patients during their procedures at the facility. Framework and Project Application REDUCING HEALTH LITERACY DISPARITIES 12 This practice improvement project will utilize the Adult Learners Theory and its four principles (Smith, 2002). Malcolm Knowles developed the theory to define the process of how adults learn compared with that of children. This theory focuses on adult learners' needs and is a comparative framework to be utilized for this project as it revolves around adult providers and patients. Framework Description Knowles was an educator who wondered how to instruct his adult students best. His theory comprises five assumptions about adult learners and four principles for teaching them effectively. The assumptions are what separate adult learners from children and include: a) adults should be capable of seeking out education on their own accord, b) adults have past experiences that can serve as a base for future adventures - whether they are positive or negative, c) many adults will seek out education that applies to their life both personally and professionally, d) adults are more engaged in education about areas related to current issues affecting their home or work life, and due to work/life progressions, e) adults are more likely to seek out education than their younger counterparts (Smith, 2002). Framework Application to Project Utilizing the Adult Learning Theory and its components for introducing a new practice protocol can allow for a better understanding of how to engage medical practitioners to ensure a more successful adoption of new information and practices. Since practice without theory becomes a practice consisting of dogma and doing things because “that’s how they have always been done,” theory should be used as the base for nursing practice and combined with clinical practice experience (McEwen, M., & Wills, E. M. 2014) to provide the best care for patients. Utilizing the Adult Learning Theory will assist in tailoring the project components into steps that play into the practitioners' need for new knowledge while engaging their self-motivation and ownership of such a project to assist in successfully integrating the new practices presented. Project Plan This project intervention provided education to the Advanced Practice Providers (Nurse Practitioners and Physician Associates) working at the Gastroenterology Associates, LLC offices in Williamsville, New York, about Health Literacy. The project plan was comprised of providing the offices’ practitioners with an overview of what health literacy is, giving the guidelines extended by the Agency for Healthcare Research and Quality to steer medical facilities into becoming health literate (2020), as well as show some specific ways it relates to their REDUCING HEALTH LITERACY DISPARITIES 13 gastroenterology practice in order to improve the patients understanding of and compliance with preprocedural verbal and written instructions. Project Design The quality improvement project aims to increase patients' understanding of and compliance with preprocedural instructions through practitioner awareness of health literacy limitations. Through health literacy education, practitioners will improve patient communication both verbally and written to facilitate a better understanding of their care and the preprocedural instructions provided to them at the practice. Needs Assessment/Gap Analysis of Project Site and Population This quality improvement project influenced the primary medical office of the Gastroenterology Associates, LLC of Western New York, and subsequently impacted the Endoscopy Center of Western New York, where they perform gastroenterology procedures for the patients in their practice. The project's main participants are the Advanced Practice Providers (APPs) employed by the medical practice. The APPs are the primary subjects for the intervention because they are the initial point of contact for patients prior to having an endoscopy procedure and relay preprocedural information to the patients mentioned above. This quality improvement project will allow the medical staff to better provide comprehensive care to the patients with the addition of improving the health and quality of life for patients through increased understanding of medical instructions and reduced delayed and canceled outpatient screening and diagnostic procedures, aligning with the facility's mission statement. Key stakeholders for the quality improvement project are the Physician owners of the practice, the anesthesia providers, office APPs, and procedural staff. The stakeholders are all invested in improving the patient's understanding of the preprocedural instructions to reduce or eliminate the delays and cancellations resulting from a poor understanding of and compliance with preprocedural instructions. Cost Analysis and Sustainability of Project The budgetary requirements for this project were discussed with the project liaisons at the facility and approved by the office manager. The endoscopy center will adjust its quarterly budget to absorb the costs of providing education to new employees as well as the printing costs for health literate material. Costs were determined as follows: • Initial training of ten APPs at $45.00/hour x one hour = $450.00, and training materials at $0.05 x ten = $0.50. REDUCING HEALTH LITERACY DISPARITIES o A total of $450.05. • New hire training assuming two per year at $45.00 x two = $90.00 • Health literate preprocedural instructions at $0.02 x 1,300/month = $26.00 o • 14 A total ongoing annual expense of $402.00. See Appendix A Project Outcomes The project outcomes were assessed and gauged based on the following goals: • Advanced practice providers verbalize an increased knowledge base related to health literacy. • Patient compliance with preprocedural instructions is improved, leading to reduced case delays and cancellations. Consent Procedures and Ethical Considerations Due to the educational nature of this quality initiative project and lack of patient participation, Institutional Review Board (IRB) approval was deemed unnecessary by both Weber State University and the Gastroenterology Associates, LLC practice. There will be no ethical or moral risks to any participants in this project. All of the assessment materials gathered for the purpose of this project will be submitted in an anonymous format and kept confidential throughout the enterprise. Instruments to Measure Intervention Effectiveness The tools that will be utilized for this project will be pre, and post-survey instruments (Appendix B) evaluated using comparative measures and qualitative statistics. The Advanced Practice Providers were given a preassessment survey to get a baseline knowledge measurement related to health literacy that will be collated with postassessment surveys. A post-assessment questionnaire (Appendix C) was also provided six weeks after the intervention took place. The endoscopy center also provided a copy of their quarterly reports on the frequency of same-day cancellations at the facility that were compared to quarterly reports provided three months after the intervention was provided. Project Implementation This quality improvement project was fully implemented when the advanced practice providers of all of the Gastroenterology Associates offices in New York state were familiar with the health literacy limitations of the REDUCING HEALTH LITERACY DISPARITIES 15 general population and how to effectively provide both verbal and written communication to their patients that are simplified to assist in reducing patient non-compliance. The participants were comprised of eight advanced practice providers, six Nurse Practitioners, and two Physician Associates working for the Endoscopy Centers of Western New York. The intervention was implemented with a pre-assessment questionnaire provided via email on September 13, 2022 (Appendix B). On November 11, 2022, the project was presented to the APPs in the facilities conference room following office hours. The project material was delivered over an hour-long meeting utilizing a PowerPoint presentation (Appendix E) along with verbal rhetoric while allowing for teach-back and questions to be addressed. Interventions The central interventions utilized for this project included collaboration with stakeholders and the employed advanced practice providers, clarifying the project's objectives, providing feedback to the providers, and allowing for teach-back of the project’s main focus relative to the facility's needs. The initial intervention originated with buy-in from the main stakeholders of the gastroenterology practices office as well as the procedural facility. Buy-in is an important part of any successful project. Without organizational and resource readiness, successful project implementation and longevity odds are reduced (Finkelman, 2017). Providing clear and specific objectives is the next step in guiding the project's direction. This will allow for more relevant communication related to the planning stage of the project's Plan-Do-Study-Act Cycle (AHRQ, 2020). Communicating the end goal of reducing procedure cancellations due to patients' misunderstanding of and disregard for the provided preprocedural instructions is necessary to ensure the project's main objective is kept in mind by all the participants. Providing feedback throughout the intervention and then receiving teach back from the practitioners following the project presentation are interventions that helped to clarify that the correct information was conveyed and retained. They are both great assessment interventions to use in teaching situations where clarity is wanted from both parties involved (Finkelman, 2017). Project Timeline The timeline for this project (Appendix D) started with a pre-assessment of the providers' current knowledge on the topic of health literacy and how it can impact medical practices (Appendix B), provided via email on September 13, 2022. This assessment was evaluated and used as a guide for the implementation of the project REDUCING HEALTH LITERACY DISPARITIES 16 utilizing a PowerPoint (Appendix E) for visual aid during an interactive lecture on ways the current health literacy practices are impacting the patient's understanding of and compliance with their provided pre-procedural instructions and methods to reduce the existing disparities. This intervention was completed approximately eight weeks after the pre-assessment questionnaire on November 11, 2022. A post-assessment survey was then provided to reassess the providers' gained knowledge a week after the intervention’s completion on November 18, 2022 (Appendix B). Two weeks following the post-assessment survey on December 9, 2022, a follow-up practice survey was given to evaluate the practice changes adopted by the providers since the quality improvement project was given (Appendix C). A full evaluation of the project’s effectiveness was then completed approximately two weeks later by comparing the endoscopy centers' quarterly pre- and post-intervention reports for a reduction in the cancellation and delay numbers (Appendix F). Project Evaluation The project evaluation was done by utilizing the responses to an identical pre- and post-presentation survey and a follow-up questionnaire that was provided to the project participants within the Qualtrics application. These surveys indicated an improved understanding of reducing health literacy disparities and the participant’s overall understanding of the topic related to their interactions with patients having outpatient procedures. The responses were evaluated, and the data was exported into a word document for further analysis of the project's outcome to determine the academic intervention’s overall success. Data Maintenance/Security The confidential data resulting from the project was maintained anonymously in the Qualtrics application and was only accessible by the sole author using an encrypted and confidential password. There were no identifying markers for the individual participants present on any of the provided survey responses. The answers were gathered using an anonymous link from the Qualtrics account. The imported survey response data was also exported completely void of any identifying markers for the Advanced Practice Providers who participated in the project and follow-up assessment surveys. Data Collection and Analysis The data gathered from the indiscriminate project implementation assessments and follow-up surveys within the Qualtrics application were uploaded onto a word document for analysis. The pre-and post-survey responses were assessed through a comparative analysis of the collected data. The responses were analyzed for an REDUCING HEALTH LITERACY DISPARITIES 17 increase in the number of correct answers chosen in the post-assessment survey when collated with the initial assessment questions provided (Table 1). Table 1 Assessment Responses of Advanced Practice Providers Variable: Pre-intervention n % 1. Limited health literacy is associated with? 5 83.3% Post-intervention n % 6 100% 6 100% 2. What is the average reading level of U.S. adults? 1 Variable: 3. What is the best reading level for written material used with patients? 16.7% Pre-intervention n % Post-intervention n % 1 16.7% 3 50% 5 83.3% 6 100% 6 100% 4. When modeling good health literacy practices, staff and clinicians should use which of the following words/phrases? You have the flu, or your flu test was positive? 5. It is a good health literacy practice to assume that each patient you communicate with has limited health literacy? 5 83.3% Note. n = APP participants The follow-up survey data was delivered on a Likert scale, and the selected answers were exported into a table to evaluate project success (Table 2). Table 2 Follow-up Responses of Advanced Practice Practitioners REDUCING HEALTH LITERACY DISPARITIES Evaluation Question: n Strongly Agree: % 18 Somewhat Agree: n % 1. Do you feel like your personal practice has changed since learning about health literacy? 6 100% 0 0% 2. My communication with patients is done with health literacy in mind? 6 100% 0 0% Evaluation Question: n 3. I have found that my patients have had an increased understanding of verbal and written instruction I provide to them since learning about health literacy? 4. I would recommend health literacy training to all healthcare personnel? Strongly Agree: % 5 83.3% 6 100% Somewhat Agree: n % 1 16.7% 0 0% Note. n = APP participants The quarterly reports provided by the Endoscopy Center for Western New York showed a reduction in procedure delays and patient cancellations showed reductions by approximately 30% and 35.7%, respectively, when comparing the pre-intervention reports to the post-intervention numbers (Table 3). Table 3 Quarterly Reports of Case Delays and Cancellations Variable: Case Delays: Pre-intervention % 20% 14% Post-intervention % 14% 9% REDUCING HEALTH LITERACY DISPARITIES 19 Case Cancellations: Findings The data analysis following the completion of the project revealed an increased understanding of health literacy limitations and ways to simplify both verbal and written practice instructions for the participating APPs (Tables 1 and 2). Knowledge of the findings associated with limited health literacy increased from 83.3% preeducation to 100% following the project implementation. The responses to the average reading level of adults in the United States started at 16.7% and increased to 100%. There were also improvements in the questions regarding the wording of specific medical phrases commonly used and whether it is good practice to assume that all patients have limited health literacy. Both questions improved from 83.3% of practitioners choosing the correct answer to 100% following instruction. The follow-up survey questions revealed a predisposition towards a beneficial view of the usefulness of the provided education related to the prevalence of limited health literacy within the general population and ways to practice more mindful of these limitations going forward. Strengths The project implementation was completed during the participant’s working hours, making participation convenient and applicable to the APP's roles in their practice and interactions with patients seen within the facility. The assessment surveys were a voluntary component of the intervention and were provided via an easy-to-access anonymous link to be taken at the convenience of the providers. Another strength was related to the compilation of the follow-up survey being modeled into a Likert scale. This allowed for assessing the data and compiling the results to evaluate the project's overall success to be done more efficiently. The topic is relevant to all aspects of medical care, making it a beneficial topic to educate providers about, no matter what the practice specialty is. Weaknesses Weaknesses of the educational intervention included a small participation number. While the practice employs a smaller number of APPs at the practice facility, not all of the providers participated in the pre-and postassessment surveys. They opted out of completing the follow-up questionnaire as well. Another weakness found was implementing a practice change in a section of the practice in that the author was not directly employed. I believe this is what led to the poor participation and difficulties in getting the providers to complete the surveys needed for assessing the project itself. REDUCING HEALTH LITERACY DISPARITIES 20 Quality Improvement Discussion Many healthcare providers are unaware of the general population’s health literacy limitations and the role this disparity can play in their patient’s comprehension of and compliance with any instructions provided (Hersh et al., 2015). Educating medical providers on the issue of health literacy has been shown to lessen the gap between what providers are conveying and what their patients comprehend. Translation of Evidence into Practice Evidence demonstrates that increasing the awareness that healthcare providers have related to health literacy disparities can improve the communication dynamic between patients and providers. Improved communication translates into a higher comprehension of and compliance with pre-procedural medical instructions provided to patients. One of the lessons gained from this evidence is how important education is for healthcare providers and how a simple informative presentation can notably impact on the care that patients receive. In addition, this knowledge can be applied to multiple other facets of medical care outside of surgery where compliance rates for medical directions are also deficient, such as prescription directives and self-care teachings. Implications for Practice and Future Scholarship Health literacy has been listed as one of the essential focuses of the Healthy People 2030 initiative (Healthy People 2030, 2020). With an increased focus on the comprehension deficits experienced by non-medical personnel, educating medical providers on ways to reduce the disparity seen between communication and patients’ understanding of that communication is a necessity of all practices that are committed to improving the quality of care they are providing. The findings of this DNP project can serve as a blueprint for a various medical practices that are negatively impacted by their patient’s non-compliance with medical instructions. Therefore, future scholarship projects should focus on larger-scale facilities with an increased participation base that can assist in replicating and corroborating this project's results. Sustainability This projects sustainability has been discussed as an included component of the new hire orientation packet to ensure that all new staff are provided the necessary information on the health literacy limitations that can be seen within the practice. Tools for the staff to utilize in order to simplify communication in an effort to reduce the comprehension gap of some patients will also be included. In general, spreading awareness of the issue, in general, REDUCING HEALTH LITERACY DISPARITIES 21 is an important factor in any deficit found within a facility's practices and can lead to a culture change that can result in reduced non-compliance issues. Dissemination Dissemination is an essential part of any project to order to pass along pertinent evidence-based interventional findings. This DNP project was reviewed with the leadership team at the Endoscopy Center of Western New York. The project findings have also been submitted to relevant national nursing journal publication platforms to increase the intervention data’s reach, along with spreading the relevance this issue has for medical providers and patients in varying practice settings. Conclusion The two primary targets of this DNP project were to 1) Increase Advanced Practice Providers' awareness of the health literacy limitations seen within the general population, and 2) Reduce non-compliance with preprocedural instructions seen at an outpatient practice facility due to health literacy deficits. This project was facilitated through the collaborative effort of the author, facility management, and practice APPs at the Gastroenterology center. A practice deficit was identified utilizing a root cause analysis technique, and health literacy was identified as a critical component of the practice shortfall. Further research into the issue revealed the widespread implications that accompany health literacy limitations for patients and medical providers. The success shown by this project in accomplishing both of the above-stated goals through a simple, yet effective educational intervention warrants increased education on this issue to other medical facilities and practices. All healthcare practices should be encouraged to align with the national objectives set forth by the Agency for Healthcare Research and Quality relating to health literacy (Healthy People 2030, 2020). REDUCING HEALTH LITERACY DISPARITIES 22 References Agency for Healthcare Research and Quality. (2020, January). Section 4: Ways to approach the quality improvement process. AHRQ. https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qiprocess/index.html American Association of Anesthesiologists. (2020, December 13). ASA physical status classification system. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system Angeles, J. (2013). Chcs fact sheet #5 [PDF]. 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Appendix A Project Budget Implementation Expenses Item Cost per Unit Number Total Cost Staff Training Time $45.00 10 $450.00 Materials $0.05 10 $0.5 20 $450.05 Total: REDUCING HEALTH LITERACY DISPARITIES 26 Ongoing Expenses – Item Cost per Unit Number Total Cost New Hire $45.00 2 per year (Assuming staff turnover) $90.00 $0.02 1300/month $26.00 Training Preprocedural Instructions Total: $116.00 REDUCING HEALTH LITERACY DISPARITIES 27 Appendix B Pre and Post Survey The following is an online survey that takes approximately 10 minutes to complete. The survey questions will be about Health Literacy. By participating in this survey, you are giving your consent. The results of this survey are reported using aggregated data, keeping responses anonymous and confidential. Data will be used for educational or quality improvement purposes to improve outcomes. If you have any questions, please contact mistyhastings@mail.weber.edu. 1. Limited health literacy is associated with: ☐ A. Higher mortality rates ☐ B. Lower levels of health knowledge ☐ C. Greater use of inpatient and emergency department care ☐ D. Poor medicine adherence ☐ E. B and D ☐ F. All of the above 2. You can tell how health literate a person is by knowing what grade he or she completed in school. ☐ A. True ☐ B. False 3. Which of the following skills are considered to be components of health literacy? ☐ ☐ ☐ ☐ ☐ ☐ A. Ability to understand and use numbers B. Reading skills C. Speaking skills D. Ability to understand what is said E. Writing skills F. All the above 4. Being anxious affects a person’s ability to absorb, recall, and use health information effectively. ☐ A. True ☐ B. False REDUCING HEALTH LITERACY DISPARITIES 28 5. What is the average reading level of U.S. adults? ☐ ☐ ☐ ☐ ☐ A. 4th-5th grade B. 6th-7th grade C. 8th-9th grade D. 10th-11th grade E. 12th grade 6. What is the grade level at which health-related information (like a diabetes brochure) is typically written? ☐ A. 4th-5th grade ☐ B. 6th-7th grade ☐ C. 8th-9th grade ☐ D. 10th grade or higher ☐ E. 11th grade or higher ☐ F. 12th grade or higher ☐ G. college level 7. What is the best reading level for written materials used with patients? ☐ ☐ ☐ ☐ ☐ A. 3rd-4th grade B. 5th-6th grade C. 7th-8th grade D. 9th-10th grade E. 11th-12th grade 8. To use good health literacy practices, staff and clinicians should use which of the following words/phrases when talking to or writing instructions for a patient or family member? Circle the word/phase in either Option 1 or 2 in each row Option 1 OR Option 2 a. Bad OR Adverse b. Hypertension OR High Blood Pressure c. Blood Glucose OR Blood Sugar d. You have the flu. OR Your flu test was positive. e. The cardiologist is Dr. Brown. OR The heart doctor is Dr. Brown. f. Your appointment is at 11:00 AM. Check-in 20 minutes early. OR Arrive at 10:40 AM to check-in. REDUCING HEALTH LITERACY DISPARITIES 29 9. It is a good health literacy practice to assume that each patient you communicate with has limited health literacy. ☐ A. True ☐ B. False 10. What strategies could all of us adopt to minimize barriers and misunderstandings for patients? REDUCING HEALTH LITERACY DISPARITIES 30 Answer Key Question Number and Answers 1. 2. 3. 4. 5. 6. 7. 8. F B F A C D B a. Option 1 – Bad b. Option 2 – High Blood Pressure c. Option 2 – Blood Sugar d. Option 1 – You have the flu. e. Option 2 – The heart doctor is Dr. Brown. f. Option 2 – Arrive at 10:40 AM to check-in. 9. A 10. Open-ended answer • This survey has been provided as part of the AHRQ Health Literacy Universal Precautions Toolkit 2nd Edition. It is a free resource provided by the Agency for Healthcare Research and Quality that is public domain and can be used and reprinted without permission. There is no mention of altering the materials provided for use. https://www.ahrq.gov/health-literacy/improve/precautions/toolkit.html REDUCING HEALTH LITERACY DISPARITIES 31 Appendix C Follow Up Questionnaire The following is an online survey that takes approximately 10 minutes to complete. The survey questions will be about Health Literacy. By participating in this survey, you are giving your consent. The results of this survey are reported using aggregated data, keeping responses anonymous and confidential. Data will be used for educational or quality improvement purposes to improve outcomes. If you have any questions, please contact mistyhastings@mail.weber.edu. 1. Do you feel like your personal practice has changed since learning about health literacy? ☐ Strongly Agree ☐ Somewhat Agree ☐ Neither Agree nor Disagree ☐ Somewhat Disagree ☐ Strongly Disagree 2. My communication with patients is done with health literacy limitations in mind: ☐ ☐ ☐ ☐ ☐ Strongly Agree Somewhat Agree Neither Agree or Disagree Somewhat Disagree Strongly Disagree 3. I have found that my patients have had an increased understanding of verbal and written instructions I provide to them since learning about health literacy. ☐ Strongly Agree ☐ Somewhat Agree ☐ Neither Agree or Disagree ☐ Somewhat Disagree ☐ Strongly Disagree REDUCING HEALTH LITERACY DISPARITIES 32 4. I would recommend health literacy awareness training for all healthcare personnel. ☐ ☐ ☐ ☐ ☐ Definitely Not Probably Not Might or Might Not Probably Yes Definitely Yes 5. What recommendations do you have for future training on health literacy? ____________________________________________________________ ____________________________________________________________ ______________________________________________________________________ __________________________________________________ ____________________________________________________________ This follow-up tool will be utilized along with the quarterly report changes provided by the Endoscopy Center of Western New York to evaluate the project implementations success, guide any changes necessary to increase the success of the intervention, and to guide expanding interventions to the practices’ other procedural facilities. No permission is needed as the DNP-L student created this survey. REDUCING HEALTH LITERACY DISPARITIES 33 Appendix D Timeline REDUCING HEALTH LITERACY DISPARITIES 34 Appendix E Health Literacy PowerPoint REDUCING HEALTH LITERACY DISPARITIES 35 Appendix F Table F3 Assessment Responses of Advanced Practice Providers Variable: Pre-intervention n % 1. Limited health literacy is associated with? 2. What is the average reading level of U.S. adults? 3. What is the best reading level for written material used with patients? 5 83.3% Post-intervention n % 6 100% 1 16.7% 6 100% 1 16.7% 3 50% 5 83.3% 6 100% 6 100% 4. To good health literacy practices, staff and clinicians should use the which of the following words/phrases? You have the flu, or your flu test was positive? 5. It is a good health literacy practice to assume that each patient you communicate with has limited health literacy? 5 83.3% Note. n = participants; a total of 6 advanced practice providers participated Table F4 Follow-up Responses of Advanced Practice Practitioners Evaluation Question: Strongly Agree: n % Somewhat Agree: n % REDUCING HEALTH LITERACY DISPARITIES 36 1. Do you feel like your personal practice has changed since learning about health literacy? 6 100% 2. My communication with patients is done with health literacy in mind? 6 100% 3. I have found that my patients have had an increased understanding of verbal and written instruction I provide to them since learning about health literacy? 5 83.3% 4. I would recommend health literacy training to all healthcare personnel? 6 100% Note. n = participants; a total of 6 Advanced Practice Providers Participated. 1 16.7%