Running head: TEACH-BACK AND ITS IMPACT ON HOSPITAL
1
TEACH-BACK AND ITS IMPACT ON HOSPITAL
CONSUMER ASSESSMENT OF HEALTHCARE
PROVIDERS AND SYSTEMS (HCAHPS)
by
Terri Cronbaugh
JOHN SCHMIDT, DNP, RN, Faculty Mentor and Chair
CATHERINE SUTTLE, PhD, ARNP, Committee Member
PEGGY O’NEIL, MSN, RN Committee Member
Patrick Robinson, PhD, Dean, School of Nursing and Health Sciences
A DNP Project Presented in Partial Fulfillment
Of the Requirements for the Degree
Doctor of Nursing Practice
Capella University
April 2017
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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Abstract 1
Successful patient outcomes rely heavily on patient engagement, 2
patient/family education, and promotion of self-management. Teach-back 3
methodology offers the healthcare team a proven technique to determine learner’s 4
health literacy and true understanding of post-acute care needs. Based on 5
supportive literature the following PICOT (problem, intervention, comparison, 6
outcome, time) question was developed: For medical/surgical patients, can teach 7
back methodology utilized during teaching improve patient satisfaction as 8
measured by transitional care HCAHPS scores over a 12-week period? The Iowa 9
Model of Evidence-based Practice (Iowa Model) was utilized to implement an 10
evidence-based practice (EBP) intervention training nurses to use teach-back 11
methodology for all education. The Conviction and Confidence Scale ([CCS], 12
IHI, 2016) was administered pre-and post-implementation to determine current 13
knowledge and use of teach-back. HCAHPS (hospital consumer assessment of 14
healthcare providers and systems) transitional care scores were evaluated for 15
patient perception of instruction. Data retrieved from the CCS showed a 65% 16
increase in use of teach-back during patient instruction. HCAHPS scores 17
indicated improvement in all three transitional care domains being measured. The 18
project was limited by reliance on staff to implement teach-back techniques; 19
promotion of the project attempted to overcome this limitation. It was determined 20
HCAHPS scores are not a reliable indicator of teach-back use or a good 21
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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representation of consumer perception due to the small number of returned 22
23 surveys. Future research should examine barriers to teach-back use for the
24 healthcare team and results should be monitored via a data scale other than 25
HCAHPS due to limited survey returns. Teach-back methodology is a simple,
26 proven technique to improve self-management and increase patient engagement
27 that impacts HCAHPS results.
Key words: teach-back, HCAHPS, engagement, patient education, patient 28 self-management 29
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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Teach-Back and Its Impact on Hospital Consumer Assessment of Healthcare 30
Providers and Systems (HCAHPS) 31
There is established significance related to transitional care, the need to 32
promote self-management and encourage patient engagement in a manner that 33
overcomes health literacy differences in a blameless environment. Patient 34
engagement has been deemed the miracle drug as engaged patients have fewer 35
readmissions, utilize emergency services less, and consume less Centers for 36
Medicare and Medicaid (CMS) expenditures (Hibbard & Greene, 2012). Teach-37
back methodology is a technique shown to be successful in building confidence, 38
assuring comprehension and engaging patients in self-care (White, Garbez, 39
Carroll, Brinke, & Howie-Esquivel, 2013). 40
Better patient coaching as well as education for healthcare providers 41
related to self-care instruction and use of teach-back can help shift current 42
practices and improve HCAHPS scores (Ladden et al., 2013). Additionally, 43
patient/family preferences and quality of life need to be considered and teach-44
back offers a consistent method to determine health literacy and the success of 45
patient teaching. A comprehensive transitional plan of care can improve patient 46
satisfaction and adherence to the determined strategy (Fan et al., 2012). The 47
teach-back method can assist the team in following the comprehensive transitional 48
plan of care to improve patient and family comprehension of post-hospitalization 49
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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needs which will improve the patient experience which affects HCAHPS scores 50
(Negarandeh, Mahmoodi, Noketehdan, Heshmat, & Shakibazadeh, 2013). 51
Implementation of teach-back as an always event, in alignment with 52
Institute for Healthcare Improvement ([IHI], (2016) recommendations, can help 53
improve patient comprehension of their health care needs which will be reflected 54
in HCAHPS results. The method eases patient transition from acute care to home 55
care and can be used with patients of all ages and to affirm teaching with family 56
members or key learners (White, Howland, & Clark, 2015). 57
Problem Description 58
Each patient transition presents a risk of dereliction in communication or 59
failure of patient understanding, thus resulting in suboptimal outcomes and 60
worsening HCAHPS scores (Allen, Hutchinson, Brown & Livingston, 2014). 61
Patients with chronic conditions require comprehensive discharge teaching to 62
ensure proper understanding of post-acute needs and to promote self-management 63
and compliance with after care. The Centers for Disease Control ([CDC], (2016) 64
shared that 117 million people in the United States of America (USA) have at 65
least one chronic disease they are managing. The CDC also noted that 86% of 66
healthcare dollars spent in the USA is related to chronic disease. Any successful 67
attempt to improve chronic disease management can have a significant impact on 68
the future financial aspect of patient care. 69
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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The community impact of successful care transition can include a 70
reduction in hospitalization, clinic visits and time off work, as well as improved 71
patient outcomes and improved quality of life. Successful transitional care will 72
address the triple aim goals of the IHI to promote the importance of the patient 73
experience, overall global population health, and continued efforts to curb 74
healthcare spending (Berwick, Nolan & Whittington, 2008, para.1). 75
Available Knowledge 76
An exhaustive review of the literature pertaining to teach-back 77
methodology was completed. Databases searched included IHI (15), CINAHL 78
(96), Cochrane (20), CDC, Joint Commission (JC) (1), PubMed (105), AHRQ 79
guideline clearinghouse (47), Joanna Briggs Institute Library (3), ProQuest 80
Nursing and Allied Health Source (0), and Google Scholar (4150). Search terms 81
included teach-back, teach back, and teach-back method. The search term 82
transitional care was also attempted with overwhelming results unrelated to teach-83
back. 84
Article inclusion was based on the depth of teach-back discussion and the 85
appraisal of the evidence provided in the article. The Johns Hopkins nursing 86
evidence-based practice model ([JHNEBP], n.d.) evidence appraisal process was 87
used to determine the level of evidence once the article was deemed worthy of 88
further evaluation. Articles that had limited information on teach-back were 89
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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excluded. Twenty articles were retained due to the wealth of information related 90
to teach-back and/or JHNEBP strength of evidence. 91
Project implementation coincided with policy development by CMS and 92
enactment of transitional care terminology codes to allow providers to charge for 93
transitional care services. Per Bloink and Adler (2013), providers may be 94
reimbursed $162.00-$229.00 for transitional care management. CMS services 95
have ethical, equity and social justice undertones as the neediest population utilize 96
CMS for healthcare payment. Development of charge codes by CMS 97
acknowledges the importance of transitional care as part of the holistic team 98
approach. 99
Gaps in discharge education are being addressed by nurses and healthcare 100
team members via transitional care plans. The return of a patient to their 101
community is important to the care team and assuring patient/family 102
understanding and information sharing with the local providers is crucial. 103
Transitional care teams try to meet the needs of the patient/family and providers 104
but there are still gaps in the communication process which can be reflected in 105
HCAHPS scores. 106
The Affordable Care Act (ACA) also addresses the need for proper 107
communication between healthcare team members. The meaningful use aspect of 108
the ACA is to improve the flow and timeliness of communication. If all providers 109
have access to the same information, the plan of care should be more cohesive 110
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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(Hinrichs & Zarcone, 2013). The true benefits of the ACA related to meaningful 111
use, are still becoming apparent, but the act has affected transitional care. 112
Patient and family preference is important when wanting to garner 113
compliance. Patient quality of life should be a primary outcome when determining 114
a plan of care (Naylor et al., 2013). Teach-back has been shown to affect the 115
patient’s perception of their quality of life and determination of functional 116
outcomes the patient hopes to reach can help the nurse guide discharge teaching 117
(Black et al., 2014). 118
Rationale 119
Agency for Healthcare Research and Quality ([AHRQ], (n.d.) describes 120
evidence based practice (EBP) in the healthcare setting as the marriage of clinical 121
expertise, best, available research evidence and consideration of patient’s 122
preferences and values. The first step in the evidence-based process is to identify 123
an evidence-based practice model to help examine a clinical opportunity for 124
improvement and assist in the research for and synthesis of appropriate evidence. 125
For this project, the Iowa Model of Evidence-Based Practice (Iowa model) 126
was utilized. The Iowa model has clearly defined components and an easy to 127
follow algorithm preventing interpretive confusion (Eberhardt, 2014). Bullet 128
points help clarify each step aiding in the use of the algorithm and the model 129
reads like a set of directives. 130
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The Iowa model can be applied to individuals or used in a systems 131
environment and is a great indicator of opportunities for improvement in the 132
clinical setting (Iowa Model Collaborative, 2015). The model addresses a team 133
approach and has implementation strategies that give suggestions to ease 134
identification of a clinical problem, pilot implementation, and evaluation of 135
changes requiring the team to evaluate the final process. Having a post-136
implementation evaluation process can help assure sustainability of a needed 137
innovation. 138
The Iowa model framework aligns with the aims of the project as use of 139
the teach-back method requires systems thinking as the healthcare team is 140
apprised of multiple disciplines. The PICOT question is supported by the 141
framework and appropriate outcomes have been determined. For the DNP project 142
only the nursing staff were educated in the use of teach-back, however there are 143
opportunities to expand to other disciplines in the future. 144
Specific Aims 145
The purpose of the project was to improve patient engagement and 146
improve transitional care HCAHPS scores through utilization of the evidence-147
based intervention of teach-back. Transition of care is a vulnerable time for 148
patients and inadequate education can increase that vulnerability (Nelson, 2015). 149
Teach-back is a process that has proven to increase patient understanding of post-150
acute healthcare needs and can in turn improve the patient experience. 151
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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Staff education in proper use of the methodology assured standardization 152
of utilization. Completion of this manuscript allows for reproduction of the best-153
practice project and continued efforts to improve patient understanding of 154
healthcare management. Encouragement from the project organization will assist 155
with stakeholder buy-in and implementation of the EBP project. 156
Organizational Background 157
The project organization has over 750 beds and is a tertiary, academic 158
hospital in the United States. The hospital has Magnet designation and nursing 159
leadership identified a need for improving transitional care HCAHPS scores. The 160
organizational Institutional Review Board (IRB) deemed that the project did not 161
meet the regulatory definition of human subjects’ research and did not require 162
IRB oversight as the project was a quality improvement project aimed at 163
implementing an approved practice. 164
The target population included all medical/surgical patients who were 165
being discharged during a 12-week monitoring period. The population of the 166
project unit was primarily composed of patients with chronic conditions with 167
comorbidities. Individuals admitted to the medical/surgical units are at high risk 168
for readmission due to the complexity of managing chronic medical conditions 169
(Prystowsky, 2015). The transitional care staff on the project unit was targeted for 170
teach-back education, with nursing staff being the primary team members. 171
172
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Methods 173
The evidence-based intervention of teach-back was implemented for all 174
patient education opportunities on the project unit. Staff was instructed on the 175
proper use of the method and provided an opportunity to practice teach-back with 176
peers in a nonthreatening environment. During education, the team was provided 177
with scenarios in which teach-back was an appropriate method for instruction. 178
Scripted pocket cards were provided for utilization during educational 179
opportunities and encouraged for use in patient interactions. 180
Context 181
The project required collaboration with the transitional care team which 182
spans across multiple departments including nursing, social work, therapy, 183
pharmacy, and medicine. There were multiple EBP projects being implementing 184
throughout the hospital. The project unit was identified by leadership as there 185
were no projects in place that could skew the data being collected. 186
The socioeconomics and culture of the community at the project hospital 187
are such that results from the EBP project could be duplicated. Being an academic 188
hospital, there are a multitude of cultures in the area. Additionally, the 189
intervention is a process that is adoptable to all cultures and socioeconomic 190
classes. 191
192
193
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Interventions 194
The CCS was administered prior to education to determine current 195
use/understanding of teach-back. Staff on a medical/surgical unit was trained in 196
teach-back via PowerPoint presentation, hands-on practice, and scripting to use 197
teach back for all patient education. The team was instructed to determine the key 198
learner(s) for each patient and assure their presence during education and do so in 199
a blameless manner. Teach back is most successful when instructions are repeated 200
throughout the hospitalization in short sessions (White et al., 2013). Therefore, 201
staff was instructed to recognize opportunities for education from admission to 202
discharge. 203
The project design included group education for the nursing staff and 204
other team members. The setting for implementation was primarily an inpatient 205
medical/surgical unit. However, some occupants were outpatients due to overflow 206
from other units because of high census in the facility. The sample for the project 207
included all medical/surgical patients being discharged from the pilot unit during 208
the project timeframe of three months. There was no identifying data collected 209
and no patients were excluded. 210
The CCS allows for a true understanding of how well the nursing staff 211
complied with use of teach-back during the pilot period. There is no reliability or 212
validity available for the scale. However, the sole purpose in using this 213
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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measurement tool is to determine nursing staff understanding and use of teach-214
back prior to implementation as well as during the active project data monitoring. 215
The project organization has many years of transitional care data that was 216
measured with the current methods of education. The data groups were relatively 217
stagnant lending validity to any changes observed during the EBP project. Given 218
the strong literature support of the intervention, expectation of teach-back being 219
an always event, and intense education for the project unit, it is believed the 220
results reflect the work that was done during the project. 221
Measures 222
The data collected for the project included HCAHPS scores specific to 223
transitional care, individualized to the project unit. Transitional care scores are 224
more sensitive than general discharge/patient satisfaction scores, thus they were 225
used to adequately identify the project intervention had significant impact in 226
patient perception of discharge instruction and transition of care. The HCAHPS 227
survey is a valid, reliable instrument. CMS completed a study analysis identifying 228
the majority of the questions on the HCAHPS have a Cronbach’s alpha coefficient 229
of internal consistency reliability of >0.80 (CMS, 2003). 230
Post-implementation data was collected through contracted Press-Ganey 231
reports, which include HCAHPS scores. Statistical analysis of pre-implementation 232
data was compared to post-implementation data. Data for three months prior to 233
team education served as the pre-implementation data. Data from the month when 234
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education was provided was excluded from both data sets as the month when 235
education was provided could represent intermittent use of teach-back during 236
education. Anticipated results were an increase in patient satisfaction as measured 237
through the transitional care specific HCAHPS question. The surveys are sent to 238
random patients upon discharge and aggregate data will allow for summary 239
statistics. Each month offers an n-value to allow for a true interpretation of results 240
in relation to the number of returned surveys. The project allowed for three 241
months of comparative data. 242
Continued use of teach-back will be sustained by the department of 243
continuum of care and individual unit leadership teams. Additional 244
implementation in other care areas will expand teach-back use. The limited cost 245
of educating the healthcare team in teach-back and its implementation make the 246
intervention efficient and easy to implement. 247
Analysis 248
The Iowa model provided a strong framework for identification of 249
organizational needs and step-by-step implementation guidelines. The data source 250
allowed for inferences from quantitative data. The data provided a complete 251
history of the previous quarter’s transitional care HCHAPS scores allowing for 252
comparison to scores during the project period of the same time length. While 253
time is a variable, it did not play a statistically significant role in the data analysis 254
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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as both sets of data were exposed to the same time opportunities between 255
reception of service and return of the survey. 256
While literature supports teach-back to be a successful intervention and 257
HCHAPS to be a valid data measure, the data groups were not as large as would 258
be hoped for. The data allowed for measurable change but the project data was at 259
the mercy of the patients to return the HCAHPS surveys. The data constraints 260
indicate the need to utilize a different data source to gain a true understanding of 261
the effects of teach-back on transitional care. 262
Ethical Considerations 263
It is vital to ensure ethical practice in healthcare to prevent patient harm 264
and promote safe practice. The project was subjected to both organizational and 265
educational institution IRBs. Both entities identified the best-practice intervention 266
as a quality improvement project with no threat to human subjects. Therefore, 267
there were no ethical aspects to the project. The intervention was a proven, 268
approved practice based on statistically significant research and publications. 269
The project originator is employed by the project organization and 270
identifies no conflicts of interest. The project unit was determined by the 271
department of nursing and the project was mentored by an organizational 272
employee. Great care was taken to assure all ethical issues were considered in the 273
design, implementation, dissemination, and data collection related to the 274
intervention. 275
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Results 276
Post-project, the team completed the CCS (IHI, 2016) a second time with 277
scores indicating 65% of the transitional care team reported using teach-back for 278
all patient education opportunities, while 100% participation would be preferred, 279
65% is a significant increase in regular use of the method. Initial survey reports 280
determined 76% of the team had used teach-back, but not as a regular method of 281
education. Thereby, 65% report making teach-back an always event. 282
HCAHPS project values (Figure 1) were determined by combining the 283
previous three month responses in each category divided by the n-value. For the 284
pre-implementation data, there were 26 surveys returned. Understanding the 285
purpose for medications received the highest, strongly agree responses at 53%. 286
Patient preference measurements averaged 27% and understanding management 287
of health responses had strongly agree 33% of the time. 288
Regarding the question, “during this hospital stay, staff took my 289
preferences and those of my family or caregiver into account in deciding what my 290
health care needs would be when I left,” (CMS, 2014) strongly agree responses 291
increased by 19%, with an average of 46%. When determining the patient’s 292
ability to manage their health, there was a 19% increase with an average of 50% 293
of respondents strongly agreeing with the HCHAPS statement “when I left the 294
hospital, I had a good understanding of the things I was responsible for in 295
managing my health.” (CMS, 2014) 296
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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Finally, the question, “when I left the hospital, I clearly understood the 297
purpose for taking each of my medications,” (CMS, 2014) responses that strongly 298
agree increased by 10%. Therefore, the overall improvements in HCAHPS 299
strongly agree responses were 45%. The resulting data indicate a strong 300
relationship between teach-back methods and increased awareness of patient 301
preferences and patient understanding of medication information. 302
As previously discussed, a better data measurement tool may be more 303
accurate when measuring patient perception of educations. The HCAHPS are sent 304
to a small percentage of patients with an ever-smaller percentage completing and 305
returning the surveys for evaluation. No modifications were made to the 306
intervention once implemented. There were no unintended consequences with the 307
intervention and all data is accounted for. 308
Discussion 309
Teach-back has been identified as a practice that engages patients allowing 310
for confirmation of understand and an open feedback loop for continued 311
educations (Koh, Brach, Harris, & Parchman, 2013). The EBP project 312
implemented a successful intervention to improve patient engagement and 313
improve HCAHPS scores. 314
The project strengthened the hypotheses that the Iowa model is an 315
effective framework for implementation of EBP identification and change. The 316
model’s algorithm proved to be easy to follow, and appropriate for both the small 317
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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unit and larger organization overall. Organizational support of the project resulted 318
in seamless implementation followed by data monitoring and compilation. The 319
project organization was consistent with practices identified by Bobay et al., 320
(2015), who noted that Magnet® facilities have shown to incorporate teach-back 321
and maintain consideration of a learner’s health literacy. 322
The credentialing body JC has identified improved transitions can result in 323
better patient outcomes and increased patient satisfaction (Shamji, Baier, 324
Gravenstein, & Gardner, 2014). CMS has also promoted moving towards 325
improved patient engagement and self-management as evidence in the IMPACT 326
Act. The EBP intervention has assisted the project organization with both JC and 327
CMS standards and provided an ethically responsible, low cost manner to 328
properly educate patients (DiChiara, 2015). 329
Summary 330
The key findings from the EBP project implementation is the need for 331
continued education of staff regarding the proven benefits of teach-back. The 332
improved HCAHPS scores indicate patients benefit from use of the method, 333
especially due to the method’s ability to provide a true understanding of a 334
patient’s health literacy and social demographic allowing staff to focus efforts 335
where they will most benefit a patient (Zoellner et al., 2016). The results indicate 336
the strength patients can draw from proper education and understanding of post-337
acute care needs. 338
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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Interpretation 339
The intervention for the project identified a strong association between 340
patient understanding and teach-back method of education resulting in improved 341
HCAHPS scores. These findings mimic what the literature indicates. Similar 342
projects found improved patient perception of quality of life and determination of 343
functional outcomes (Black et al., 2014). The project impacted the unit 344
significantly with a 25% improvement in HCAHPS scores specific to transitional 345
care. System wide, teach-back is a cost-effective method to reduce consumption 346
of health-care resources. 347
The anticipated and observed outcomes aligned with what was expected. 348
Literature shows improve understanding and increased satisfaction when teach-349
back is used which was indicated in the improved HCAHPS scores. The results 350
were similar to previous, published teach-back interventions (Caplin & Saunders, 351
2015). 352
Limitations 353
The project was limited in its reliance on the transitional care team to 354
implement the intervention. Regarding internal validity, the CCS (IHI, 2016) 355
allowed subjective responses to be provided by the team. There is concern that 356
staff may have inflated their use of teach-back to appear compliant with the 357
intervention. To adjust for this limitation, staff was requested to leave the surveys 358
anonymous and be honest in their answers. 359
TEACH-BACK AND ITS IMPACT ON HOSPITAL
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Conclusions 360
The project has proven useful in encouraging staff to use the evidence-361
based method of teach-back for all patient education opportunities. Patient impact 362
was evident in the improved transitional care HCAHPS scores. The project is 363
sustainable throughout the organization with minimal implementation costs. 364
Teach-back is a concept that can be spread to other context both within and 365
outside the project organization. Further study should utilize a data set that 366
captures a better snapshot of overall patient response to teach-back methodology. 367
The EBP project indicates teach-back is a method that should be used in nursing 368
practice and sustained at a level that promotes its use. 369
370
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