An account of my personal experience attempting to navigate around a local, rural hospital in New England.
Health literacy is described by Dr. Rima Rudd as, “…an interaction between people’s skills and the demands of systems." Each interaction is an opportunity for a positive, neutral or negative experience to take place. As Rudd points out in her lecture, hospitals can become like “…a complex maze” over time, when new wings are constructed and floor plans are shifted around. About a year ago, I visited a rural hospital I had never been to, located in New England, to experience what it would be like to find my way around for the first time.
This hospital was built in the early 1900's and is a 100-bed community hospital serving 100,000 people in a rural area. This location is like one of these hospitals that Dr. Rima Rudd refers to in her lecture; it started small and over the years added wings and outbuildings. During my visit, particular attention was paid to the approach to the building (the driveway and parking lot), the lobby, navigating the hallways, and for no particular reason, finding the Imaging Center.
The sign for the hospital at the main entrance did not match the branding seen elsewhere on billboards and the hospital website. As someone navigating to the hospital for the first time, I was unsure if I was at the correct location due to this inconsistency. Helen Osborne wrote about the importance of not only written communications for health literacy, but the experience of the environment being important as well. As Osborne points out in chapter ten of her book, patients and doctors often talk about scary or vulnerable topics, so creating a welcoming environment is key.
The signs for parking at the hospital were not prominent and I ended up missing the main parking lot because it seemed too far from what looked like the main entrance. After turning back around, I saw a small sign on a building, directing all “hospital visitors” back to the main parking lot I had already passed. Confused and annoyed already.
Once I parked, I walked around a building that was between the parking lot and the main entrance. The parking and hospital signs were written in English and some were large and in serif font while others were older written in an italicized font. At this point in my visit, I was only guessing that I was entering the main entrance and not some other part of the hospital.
Upon entering the lobby, I walked to the “visitor desk” and requested a map of the hospital; I was told they did not have maps. I walked to the “patient access” desk nearby and requested a map, but the woman informed me that “patient access” dealt with the financial aspect of a patients stay and that I should consult the “visitor desk” for a map. Osborne recommends that hospitals provide easy to read, accurate and up-to-date maps for visitors; and for those who don’t like maps, human guides. No maps and my human guides just bounced me back and forth like a ping pong ball.
My intention upon visiting this hospital was to locate the Imaging Center. Without a map, I looked around: on the wall of a main hallway was a clearly written list of destinations, with arrows pointing the way. The “Imaging Center” was one of those destinations. Below the header, “Imaging Center” in smaller script were listed, “Mammograms”, “MRI’s”, “CT Scans” and so on, helping me to understand the types of services offered there, which was helpful.
Getting there was easy. In the Imaging Center, I saw two informational pamphlets on a counter. There were no staff members present in the Imaging Center. The pamphlets did not provide me relevant information about the Imaging Center, missing a crucial interaction point to educate and inform the patient.
Because there was nothing else and no one else around, I picked up the pamphlets. The first pamphlet from the Imaging Center was a single-fold piece written in English and was about, “Patient Financial Assistance and Resources”. The header could be written more simply in terms of the patients needs, such as “Paying for your stay” or “Affording your visit”. The pamphlet was laid out very simply with the bottom third of each side of the pamphlet being white space. Phrases in the pamphlet such as, “Financial services”, “payment plan”, and “past due balances” as well as “medically necessary services” and “within the approval period” assumed a certain level of understanding from the reader. There was inconsistency in using the terms “past due balance” and “past balance owed” to mean the same thing. The sentences were short and well-written and the pamphlet made it clear whom to contact with any questions, but offered little else.
The second pamphlet was a two-sided piece and was about, “Understanding Your Health Insurance”. It seemed geared towards people with little understanding of how health insurance works. Hey, that's me! This pamphlet was written in English and contained phrases that were undefined, such as “down payment” and “meet the deductible”. On the back of the pamphlet, three common insurance terms were defined: deductible, co-payment and co-insurance. The short definition for “deductible” was “A set amount patients pay during each policy year before the insurance company begins paying”. I found issues with this definition in that “policy year” could be confusing and the phrase, “the insurance company begins paying” does not clarify for what the insurance company pays and to who. This two-sided pamphlet attempted to explain a complex aspect of healthcare in too short of a time and did not really advance my understanding. This pamphlet did not contain much white space either, making it feel like a longer read. Both pamphlets had to do with the financial side of healthcare, be it payments or insurance, and little to do with the patient’s medical experience or needs.
Reflections on my visit
This hospital is primarily a community hospital, serving a rural area with a focus on improving access to primary care. To improve the initial impression, the hospital should create clearer and more numerous signs in order to direct patients where to park and which building to enter. Setting visitors at ease upon arrival takes into account their possibly vulnerable emotional and mental state.
The hospital should change their main entrance sign to match their branding. The hospital should create a pamphlet with a basic orientation to the hospital, including a map of the hospital.
The “Patient Access” desk in the lobby should be renamed to make it clearer that is where a patient would go if they had insurance or billing questions. Signs directing patients to different hospital areas in the building should be increased and should build on the already well-done directional sign I encountered. Pamphlets specific to different departments in the hospital should be created; for example, there should be a pamphlet in the Imaging Center orienting new patients to the services offered there.
Overall, visiting this hospital opened my eyes. Not just this hospital, but other hospitals and programs I have visited could become more patient-centered by thinking of the needs of their patients first instead of the financial needs.
As Zarcadoolas suggests, “…creating “in-place” or “just-in-time” instructions…” helps get patients just enough information when and where they need it without being overwhelming or irrelevant. Providing better translation services, at the very least in the form of pamphlets in different languages, would help someone navigate the hospital better whose first language is not English. In all publications, whether pamphlets or signs, the hospital should reduce the use of phrases with inferred meanings and should do a better job at breaking down concepts into simple terms.
Overall, my visit to his hospital was pleasant but presented several barriers to the patient with low health literacy. I visited as a well person, able to handle stress and confusion. My emotional and mental state were grounded and neutral. If I had been compromised emotionally or physically at all, and felt more vulnerable, this would have been a draining experience.
If you work in a hospital or treatment program, ask someone to visit your facility and provide you with feedback on their experience. It might open your eyes to barriers that can be easily removed, improving that initial impression and making your clients more comfortable. As often as one can, health practitioners should put themselves in the shoes of those they serve to ensure the delivery and experience of care is happening as intended.
Osborne, H. (2012). Health Literacy from A to Z. Jones & Bartlett Publishers.
Rima, R. (2012, November). Dr Rima Rudd talks about the complexity of current health
care systems. Lecture presented at the New Zealand Health Literacy Conference.
Video lecture excerpt retrieved from https://www.youtube.com/watch?v=yKmAtrl8WcY
Zarcadoolas, C., Pleasant, A., & Greer, D. S. (2006). Advancing health literacy: A
framework for understanding and action (Vol. 45). John Wiley & Sons.