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Improving illiterate patients' understanding through quality improvement

The new picture-based discharge proforma has markedly improved understanding of discharge medication regimes among illiterate patients.

Adherence to a hospital discharge medication regime is crucial for successful treatment and to avoid increasing rates of drug resistance. Anecdotal evidence in Services Hospital, Lahore (Pakistan) suggested that the relatively high levels of illiteracy in the patient population was a major factor in poor adherence.

Baseline measurement revealed that 48% of all the hospital’s patients were illiterate with just 5%-12% of illiterate patients being able to interpret their handwritten discharge prescription after leaving hospital.

BMJ published the quality improvement project that intervened by designing a new discharge prescription proforma which used pictures and symbols rather than words to convey the necessary information. The new standardised form became a picture rather than word based. For example, instructions such as ‘bd’ and ‘tds’ could be replaced by pictures of a sun rising over the mountains to represent morning, and moon and stars to represent night time.

Repeated surveys demonstrated large relative increases in comprehension of the new proformas amongst illiterate patients with between 23%-35% of illiterate patients understanding the new proformas. Literate patients who received counselling with the new proforma understood it 100% of the time (vs. 100% with the old handwritten TTO). Illiterate patients who received counselling with the new proforma understood it 35% of the time (vs. 12% with the old handwritten TTO)

  • Illiterate patients who did not receive counselling with the new proforma understood it 23% of the time (vs. 5% with the old handwritten TTO).

The new picture-based discharge proforma has markedly improved understanding of discharge medication regimes among illiterate patients. The project demonstrated a relative increase in understanding of 192% among illiterate patients who received counselling and a relative increase of 360% among illiterate patients who were not counselled.

This intervention shows a remarkable improvement in healthcare and its findings exist among other articles in the new peer-reviewed BMJ Quality Improvement Reports journal, all constructed around the SQUIRE guidelines to make them easy to search and to understand.

BMJ Quality Improvement Reports publishes quality improvement work, original research and reviews. The online-only, open access journal covers all aspects of quality and patient safety in healthcare.

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