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Crystal Clear: Ireland's first health literacy quality standard mark for pharmacies adn general practices


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Helen Ryan
Health LIteracy Conference: Making LIfe Better
Belfast 2018

Published in: Health & Medicine
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Crystal Clear: Ireland's first health literacy quality standard mark for pharmacies adn general practices

  1. 1. Crystal Clear: Ireland's first health literacy quality standard mark for pharmacies and general practices 5th Health Literacy UK Conference Helen Ryan, NALA, 16 February 2018
  2. 2. Outline Crystal Clear programme Research from pharmacy perspective: 2017 Questions
  3. 3. What is health literacy and numeracy? Your treatment is... I can’t believe I have... It is about mutual understanding
  4. 4. Recent research found… 39% of Irish people calling for less medical jargon from their healthcare professionals People aged 15 - 34 years were least likely to ask a doctor, nurse or pharmacist to explain things they don’t understand Embarrassment was ranked as the main reason for not seeking more information from a healthcare professional (24%) 45% couldn’t define the term prognosis Irish Health Literacy Research 2015
  5. 5. EU Health Literacy Survey 10.3% had inadequate health literacy 29.7% had problematic health literacy Limited health literacy rate 40% (2012)
  6. 6. Healthy Ireland – Irish Government’s national framework for action to improve the health and wellbeing of the people (2013 – 2025). It contains the first ever Government commitment to health literacy: HSE Healthy Ireland Implementation Plan 2015-17 Health Literacy Action 45 – Promote and provide national tools for training, resource development, and health literacy audits in services to raise standards of health literacy among patients, service users, and carers. “Address and prioritise health literacy in developing future policy, educational and information interventions”
  7. 7. The Crystal Clear Mark 2015-17 Online Audit Tool National programme launched in 2015 offering pharmacies and general practices the opportunity to gain a unique quality mark. This Crystal Clear Mark recognises pharmacies and general practices that deliver a health literacy friendly service to their patients. You must show that you comply with nine quality standards by completing an online audit tool. The standards and questions look at policies and procedures; communications, staff training and awareness and evaluating and improving. It was developed by The Irish Pharmacy Union (IPU), Merck Sharp & Dohme (MSD) and NALA.
  8. 8. Nine standards to become a Crystal Clear pharmacy or general practice Policies and procedures 1. We have a literacy friendly policy in place. 2. We have specific procedures to help patients find and use the important information and instructions. Staff awareness 7. All our staff are aware of literacy friendly work practices. 8. Our staff can respond sensitively to the literacy and numeracy needs of our patients. Communications 3. Our staff use plain English when speaking with patients. 4. We use plain English on our medication labels OR in our written information 5. We check that patients understand what we have told them. 6. The layout of our pharmacy/practice is clear. Evaluating and improving 9. We regularly evaluate and continually improve our literacy friendly service.
  9. 9. Getting the Mark Steps: • Go to and complete the audit. • NALA assesses the application and sends back feedback. Sometimes we need extra information or to chat through an answer so we talk on the phone. • When your application meets the standards, we send you the mark (sticker for your door) and certificate. In three years, 66 pharmacies and five general practices have achieved the mark.
  10. 10. Crystal Clear Research 2017 Doris J Ravotas, a researcher, from Western Michigan University, US, spent three months with NALA to do a research study. The study looked at understanding the process and experience of Crystal Clear from the pharmacy provider perspective. Research methodology • Interviews with program organisers • Review of specific health literacy literature • Qualitative review of data submitted for each standard through the application process. Constant Comparison method of Content Analysis to Identify themes • 4 site visits that included interviews on the Crystal Clear process with the pharmacist applicant, brief talks with the staff in each pharmacy and pictures of the pharmacy layout. • 1 email exchange with an additional pharmacist applicant.
  11. 11. Crystal Clear Research 2017 Key summary points The role of a pharmacist in the correct use of medications can not be over-emphasised. The main benefit of applying for the Crystal Clear Mark is increased daily awareness. This awareness transforms into problem solving and actions that enable patient understanding. All of the pharmacies that were interviewed adopted new approaches from the audit process itself and they felt validated for the literacy friendly work they were already doing. More emphasis needs to be made on plain language for everyone – using universal precaution is important as lack of understanding is not always evident and not just based on literacy level.
  12. 12. Medication labels Biggest challenge for Pharmacists: • Many regulations • Electronic information systems • How doctors write prescriptions varies • What looks like plain language is often not understood Take one tablet three times per day Take one tablet at breakfast, one lunch and one at dinner 79% 97%
  13. 13. Medication labels Challenges for Parents: • Over the counter medications have to be adjusted for age and weight • Dosages change as children grow • How to measure is often unclear • Plain language often not used • Inserts are usually more complicated
  15. 15. Medication labels Clonamax 500 mg tablets (penicillin antibiotic for infection) Take 1 tablet in the morning and 1 tablet in the evening Warning: Take the medicine until it is all gone, unless you are told to stop. Joe Bloggs Quantity: 14 Greenview Pharmacy Date: 22 October 2017 After
  16. 16. Medication labels best practice Preferred Hard to read when you… Use lower case letters Use CAPITALS Use a readable typeface, sans serif fonts like Arial or Tahoma are best Use serif font such as Times New Roman Use minimum of size 11 font, ideally size 12 Use 10 point or lower Use biggeror bold for emphasis Use underline or italicise Be specific Are vague Use numbers instead of words Use words for numbers – 2 is better than two Use active voice – Take 2 tablets Use passive voice – One tablet twice a day Use everyday words Use medical jargon or abbreviations Align text to the left Centre the text Add the purpose of the medication Leave off the purpose of the medication
  17. 17. Increased daily awareness Recognising signs of literacy and numeracy needs Not filling out forms completely Unwillingness to approach the counter Medicine review (not coming for refill, too many left) Uneasy body language including facial expressions Avoid signing documents or form Subtle cues in language Describing products by colour Non-English speakers Confused about how many tablets to take and when to take them Older people Doesn’t respond when use teach back “My wife looks after my tablets”
  18. 18. Increased daily awareness Responding to literacy and numeracy needs Explain instructions or information from doctor’s reports Use a little of the other languages that people use Offer to fill out forms or complete cheques (without signing) Note down literacy needs as a reminder for other staff Include family members in discussion Assist in setting up pill boxes Pictorial/symbols (i.e. sun/moon) Blister packs with pictures Use visual aids and diagrams Use colour coding (blue for night)
  19. 19. New approaches • Providing a “Virtual Pharmacist” through their website, where patients can ask any questions relating to their medicines and get an instant response. • Providing a follow up service after the patient medicine consultation, where relevant information is prepared and emailed to the patient. • Backing up communication with a written “my Medication Record” form. In this the pharmacy list each medicine the patient is taking and the reason they are taking them. They also emphasise important points with a highlighter pen.
  20. 20. Good practice examples We have laminated some pictograms for those who do not speak English. We have one man who has low literacy but understands numbers so we try use numbers in our explanations. We introduced a new sticker to warn about interactions with other medications. We have new policies in place to deal with the confusion over generic medications.
  21. 21. Plain language
  22. 22. Plain language examples Laminated reminder cards at the till point reminding staff to: Keep it simple Avoid jargon Name the quantity of tablets they are to take rather than the strength. For example: For paracetamol 500mg, say take two tablets up to four times a day rather than saying take 1 gram up to four times a day. Refer to tablets by condition first before using the drug name. For example: 'your blood pressure tablets, Amlodipine‘. Avoid unnecessary complicated terms. For example: “put 2 drops” into the left ear rather than “instil 2 drops”.
  23. 23. Getting your message across better Plain English Plain numbers Plain speaking Plain numbers is about presenting numerical information so we readily understand it. Spoken communication is two way, so at any point you can be the sender or the receiver. It is about: • What you say • How you say it • Body language A way to present information so that the user can understand it the first time they hear or read it. Plain English means: • writing accurately and clearly for the intended reader; • avoiding jargon, except for people who will understand it; and • using clear layout and design so the information is easy on the eye.
  24. 24. Using plain English NALA website on Plain English Language, punctuation and grammar Structure Page design NALA checklist for documents and forms.
  25. 25. Using plain English 1.Think of whom you are writing to and why. 2.Be personal and direct. 3.Keep it simple and define any essential jargon and abbreviations. 4.Use a clear font such as Arial or Verdana and use 12 point. 5.Keep sentences to an average of 15 to 20 words. 6.Use signposts – for example, table of contents, headings and bulleted lists NALA website on Plain English
  26. 26. Conclusion We all need good health literacy skills Becoming health literacy aware means better health services Delivering a health literacy friendly service is more effective Making one small change can make a difference
  27. 27. Further information Helen Ryan Policy Officer Sandford Lodge Sandford Close Ranelagh Dublin 6 Tel: (01) 412 7900 Email: Website: Plain English: Family: @nalaireland nalaireland nationaladultliterac
  28. 28. Health Literacy Tools and Resources • Health Pack • Health Exercises • Health Literacy Audit • Report of pilot in 4 sites • HSE Guidelines for communicating clearly • Writing and Design Tips
  29. 29. Ask me 3: Patient awareness campaign What is my main problem What do I need to do Why is it important for me to do this Good communication with patients means that they will know and understand: 2 1 3 Adapted from Ask Me 3