2. Improve Spoken Communication Doing Well Needs Not Doing Not Sure or N/A Tools to Help 8. All staff members speak clearly (e.g., use plain, everyday words and speak at a moderate pace). ☐ ☐ ☐ ☐ 4-Commun. Clearly 9. All staff members listen carefully to patients without interrupting. ☐ ☐ ☐ ☐ 4-Commun. Clearly 10. All staff members limit themselves to 3-5 key points and repeat those points for reinforcement. ☐ ☐ ☐ ☐ 4-Commun. Clearly 11. All staff members use audio/video materials and/or visual aids to promote better understanding (e.g., food models for portion sizes, models of body parts, instructional health videos). ☐ ☐ ☐ ☐ 4-Commun. Clearly 12-Use Health Ed. Material Effectively 12. Our practice ensures patients have the equipment and know-how to use recommended audio-visual materials and Internet resources. ☐ ☐ ☐ ☐ 12-Use Health Ed. Material Effectively 13. All clinicians talk with patients about any educational materials they receive during the visit and emphasize the important information. ☐ ☐ ☐ ☐ 12-Use Health Ed. Material Effectively 14. All staff members ask patients to state key points in their own words (i.e., use the teach-back method) to assess patients’ understanding of information. ☐ ☐ ☐ ☐ 5-Teach-Back Method 15. Clinicians routinely review with patients all the medicines they take, including over-the-counter medicines and supplements, and ask patients to demonstrate how to take them. ☐ ☐ ☐ ☐ 5-Teach-Back Method 8-Brown Bag Review
3. Improve Written Communication Continued Doing Well Needs Not Doing Not Sure or N/A Tools to Help 33. The walls and bulletin boards are not covered with too many printed notices. It is easy for anyone to pick out the important information. ☐ ☐ ☐ ☐ 13-Welcome Patients 34. Office signs use large, clearly visible lettering and plain, everyday words such as and “Health Center” rather than formal words such as “Ambulatory Care” or “Primary Care Practice.” ☐ ☐ ☐ ☐ 13-Welcome Patients 35. Office signs are written in English and in the primary languages of the populations being served (e.g., if most of the patients speak English or Spanish, signs are written in English and Spanish). ☐ ☐ ☐ ☐ 13-Welcome Patients 4. Improve Self-Management and Empowerment Doing Well Needs Not Doing Not Sure or N/A Tools to Help 36. Our practice creates an environment that encourages our patients to ask questions (e.g., asking “What questions do you have?” instead of “Do you have any questions?”) and get involved with their care. ☐ ☐ ☐ ☐ 13-Welcome Patients 14-Enc. Questions 15-Make Action Plans 37. Clinicians help patients choose health improvement goals and develop action plans to take manageable steps toward goals. ☐ ☐ ☐ ☐ 15-Make Action Plans 38. Clinicians consider their patients’ religion, culture, and ethnic customs when devising treatment options. ☐ ☐ ☐ ☐ 10- Consider Culture
46. Staff members ask patients if they have trouble reading or understanding and using numbers. ☐ ☐ ☐ ☐ 20-Literacy and Math Resources 47. Our practice maintains an list of community resources and refers patients as needed. ☐ ☐ ☐ ☐ 18-Non-Medical Support 20-Literacy and Math Resources 48. Staff members help patients access adult literacy and math programs. ☐ ☐ ☐ ☐ 20-Literacy and Math Resources 49. Our practice shares important referral information (e.g., reason for referral, pertinent medical history, test results) directly with other health care clinicians. ☐ ☐ ☐ ☐ 21- Referrals 50. Staff members offer patients help with referrals, such as making an appointment. ☐ ☐ ☐ ☐ 18-Non-Medical Support 20-Literacy and Math Resources 21- Referrals 51. Staff members confirm patient follow through after a referral is made. ☐ ☐ ☐ ☐ 6-Follow up 18-Non-Medical Support 20-Literacy and Math Resources 21- Referrals