Organizational assessment of health literacy within an academic medical center

Health literacy is defined as “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”¹ Recent studies in surgery have shown that over one-third of patients have low health literacy, which has been associated with higher risk for worse postoperative outcomes and lower health-related quality of life.² As healthcare systems become increasingly complex, patients with low health literacy are being left behind.

Healthy People 2030 notes that a patient’s personal health literacy is a contextual concept largely influenced by the healthcare organization and its services.¹ As a result, organizational health literacy (OHL) has emerged as a level of intervention to improve patient interactions with the healthcare system. OHL refers to organization-wide efforts to improve healthcare navigation and understanding of information and services to help patients take better care of their health.³ Many healthcare organizations lack proper application of health literate approaches to patient care, and these gaps should be addressed to improve health outcomes including those in surgery.⁴

Few studies have assessed OHL or identified actionable ways to improve it. The purpose of this study was therefore to assess the OHL of a large academic department at an academic medical center (AMC) and to identify barriers to OHL. This cross-sectional survey-based study assessed OHL at a single academic department at a tertiary-care AMC. The AMC in the study is in a state where white residents comprise 68.9% of the population, followed by Black residents at 26.8%; 86.9% of the population have an education level of high school or higher, and median household income is $52,035 with a poverty prevalence of 14.9%.⁵ The OHL was assessed with a validated 10-item survey (HLHO-10) based on the ten attributes of a health literate healthcare organization as determined by the National Academy of Medicine (NAM).⁶ Table 1 lists the items in the HLHO-10 survey and the specific health literacy attribute represented by each item. The survey was administered to the faculty members of the Department of Surgery (n = 118), and the scores for each question ranged from 1 to 7 in a Likert scale, with 1 being ‘absolutely not’ to 7 being ‘to a very large extent.’ After the responses were collected, descriptive analyses were conducted to observe the mean, median, standard deviation, skewness, minimum, and maximum scores for each question. Additional covariates of interest included faculty rank, biological sex, and surgical department divisions.

Table 1.

Health Literate Health Care Organization 10-Item Questionnaire (HLHO-10) and Mean Score of Each Attribute from Highest to Lowest (Likert scale: scores range from one to seven, with one being “absolutely not” to seven being “to a very large extent”).

Questions	Attribute	Mean (SD)
Are efforts made to ensure that patients can find their way at your organization without any problems (e.g. direction signs, information staff)?	Easy Access/Navigation	4.98 (1.57)
Are there communication standards at your organization which ensure that patients truly understand the necessary information (e.g. translators, allowing pauses for reflection, calling for further queries)?	Clear Interpersonal Communication	4.23 (1.67)
Is it ensured that the patients have truly understood everything, particularly in critical situations (e.g. medication, surgical consent), at your organization?	Informed Consent	4.14 (1.39)
Is information made available to different patients via different media at your organization (e.g. three-dimensional models, DVD, picture stories)?	Media Variety	3.83 (1.68)
Is individualized health information used at your organization (e.g. different languages, print sizes, braille)?	Patient Accommodation	3.82 (1.64)
Is the management at your organization explicitly dedicated to the subject of health literacy (e.g. mission statement, human resources planning)?	Effective Leadership	3.82 (1.48)
Is the topic of health literacy considered in quality management measures at your organization?	Integration with Healthcare System	3.71 (1.62)
Does your organization communicate openly and comprehensibly to patients in advance about the costs which they themselves have to pay for treatment (e.g. out-ofpocket payments)?	Clearly Explained Benefits/Coverage	3.54 (1.69)
Is health information at your organization developed by involving patients?	Patient Involvement	3.23 (1.50)
Are employees at your organization trained on the topic of health literacy?	Employee Training	3.08 (1.49)

SD = standard deviation.

Among the 118 attending physicians of the Department of Surgery who received the survey, 65 (55%) responded. Responders were 78% male and 22% female, with 17 assistant professors (26%), 23 associate professors (35%), 15 professors (23%), and 10 division directors (15%). By race, 49 were White (75%), 14 Asian (22%), and 3 Black (3%). Age of the responders ranged from 33 to 81 with a mean of 49.02 (SD = 10.96), and their years in practice ranged from 8 to 57 with a mean of 22.00 (SD = 10.64). By division, 15 were in the Division of Gastrointestinal Surgery (23%), 9 in Trauma and Acute Care Surgery (14%), 6 in Vascular and Endovascular Surgery (9%), 6 in Surgical Oncology (9%), 5 in Breast and Endocrine Surgery (8%), 8 in Transplantation (12%), 4 in Plastic Surgery (6%), 6 in Cardiothoracic Surgery (9%), and 6 in Pediatric Surgery (9%).

The overall mean OHL score was 3.84 out of 7.00 (SD = 0.54) with individual mean scores ranging from 3.08 to 4.98. The mean scores of each attribute are shown in Table 1. The attribute “easy access/navigation” scored the highest with a mean score of 4.98; this attribute assessed access to health information and navigation. The attribute “employee training,” which assesses employee health literacy training with an emphasis on “expert educators” and progress monitoring, scored the lowest with a mean of 3.08. This latter domain represents an identifiable area for intervention.

Of the few published studies examining OHL, a range of overall scores have been reported. A study done at a major AMC (N = 463) showed an overall mean employee score of 4.70 on a 7-point Likert scale.⁷ Another study (N = 74) that collected responses across 13 hospitals in North Texas showed an overall mean score of 4.59.⁸ While variations are evident in scores across domains, the most noteworthy finding is that the attribute “employee training” consistently rated as one of the lowest three domains across these studies which make it a high impact area for intervention. Our study additionally showed no significant difference in overall OHL scores between academic ranks (P = 0.07) and sex (P = 0.64). However, OHL mean scores stratified by respondent’s division within the surgical department revealed statistically significant differences (P < 0.01). Plastic surgery’s score was highest at 5.01 and surgical oncology scored lowest at 3.12, suggesting that variations exist in perceived levels of OHL even within a department.

Improving OHL is a challenging task as its novelty and poor recognition pose major barriers. Therefore, improving OHL should start with raising awareness and commitment to building OHL, as this article hopes to convey. Next, the organization should assess its OHL and identify barriers, create and institutionalize a plan to improve OHL, and monitor its progress.⁹ Our AMC scored lowest in “employee training.” To address insufficient “employee training,” internal review efforts are currently underway to identify the gaps in current employee training. Recognizing these gaps will allow for opportunities to better train employees to be health literacy champions. These institutionalized plans can then be monitored to assess progress and be further refined. To provide the best health literate care, organizational-level strategies such as these need to be implemented.

Our study has several limitations. First, the AMC’s OHL assessment was not comprehensive as only the Department of Surgery participated in the study, excluding other healthcare professionals from other Departments. The study, however, was designed to demonstrate the feasibility of using the validated instrument, and the department was chosen given its size, diversity of faculty members, number of divisions, and critical role to the AMC. Second, the survey was conducted from physicians at a single AMC in the Southeast and is not representative of other healthcare organizations in other settings. Very few studies exist, however, and thus our study provides a reference point for other organizations to compare OHL assessments. Third, participants of OHL assessment survey are employees of the AMC, and there may be inherent biases in the results. Finally, there may also be selection bias in which faculty responded, as they may be more invested in organizational health literacy and therefore know more about resources and initiatives than those who did not complete the survey.

This pilot study shows that organizational health literacy is important, measurable, and actionable. Opportunities exist to make an organization more health literate with potential benefits to patients of all health literacy levels. As personal health literacy is closely related to OHL, improvements in OHL will address patient health literacy and lead to better health outcomes in patients. Future research should focus on assessing OHL in other academic medical centers and sharing efforts to improve OHL at every organizational level.

Abbreviations:

SD

standard deviation