| 1 | 2 | 3 | Blank | N/A | Total | |
|---|---|---|---|---|---|---|
| I. Print Materials | ||||||
| 1. We use printed materials to advise patients about services in rest of clinic. | 100.0% | 0.0% | 0.0% | 0.0% | 0.0% | 100.0% |
| 2. Print materials are written in simple and clear language, avoiding use of technical jargon and medical terms: | ||||||
| a) bottle labels | 0.0% | 12.5% | 87.5% | 0.0% | 0.0% | 100.0% |
| b) warning labels | 0.0% | 25.0% | 75.0% | 0.0% | 0.0% | 100.0% |
| 3. Print materials are designed with lots of white space: | ||||||
| a) bottle labels | 0.0% | 62.5% | 37.5% | 0.0% | 0.0% | 100.0% |
| b) warning labels | 12.5% | 50.0% | 25.0% | 0.0% | 12.5% | 100.0% |
| 4. Graphics are used to decrease dependence on text: | ||||||
| a) bottle labels | 75.0% | 12.5% | 0.0% | 0.0% | 12.5% | 100.0% |
| b) warning labels | 25.0% | 50.0% | 25.0% | 0.0% | 0.0% | 100.0% |
| 5. Graphics are used to decrease dependence on text--non-English materials: | ||||||
| a) bottle labels | 0.0% | 25.0% | 75.0% | 0.0% | 0.0% | 100.0% |
| b) warning labels | 0.0% | 25.0% | 75.0% | 0.0% | 0.0% | 100.0% |
| c) monographs | 0.0% | 25.0% | 75.0% | 0.0% | 0.0% | 100.0% |
| d) patient education materials | 25.0% | 12.5% | 50.0% | 0.0% | 12.5% | 100.0% |
| e) informational posters | 50.0% | 12.5% | 37.5% | 0.0% | 0.0% | 100.0% |
| 6. Font is more than 12pt: | ||||||
| a) bottle labels | 12.5% | 0.0% | 62.5% | 25.0% | 0.0% | 100.0% |
| b) warning labels | 37.5% | 25.0% | 12.5% | 25.0% | 0.0% | 100.0% |
| 7. Print materials are easy for adults with limited health literacy: | ||||||
| a) bottle labels | 0.0% | 37.5% | 62.5% | 0.0% | 0.0% | 100.0% |
| b) warning labels | 25.0% | 50.0% | 25.0% | 0.0% | 0.0% | 100.0% |
| c) monographs | 37.5% | 37.5% | 25.0% | 0.0% | 0.0% | 100.0% |
| d) patient education materials | 12.5% | 37.5% | 25.0% | 0.0% | 25.0% | 100.0% |
| e) informational posters | 37.5% | 12.5% | 25.0% | 0.0% | 25.0% | 100.0% |
| 8. We regularly review printed material to check how easy it is to read | 62.5% | 25.0% | 0.0% | 0.0% | 12.5% | 100.0% |
| 9. We modify materials that are difficult to understand/read. | 25.0% | 50.0% | 0.0% | 0.0% | 25.0% | 100.0% |
| 10. We consult with non-pharmacy staff/committee on written materials. | 62.5% | 12.5% | 0.0% | 0.0% | 25.0% | 100.0% |
| 12. Our staff receives training on how to identify, prepare, simplify materials. | 62.5% | 25.0% | 12.5% | 0.0% | 0.0% | 100.0% |
| II. Clear Verbal Communication | ||||||
| 13. We distribute education materials to help patients understand and remember. | 25.0% | 50.0% | 25.0% | 0.0% | 0.0% | 100.0% |
| 14. Staff has had training to explain medical jargon to patients. | 25.0% | 37.5% | 37.5% | 0.0% | 0.0% | 100.0% |
| 15. We use "teach back" method. | 25.0% | 75.0% | 0.0% | 0.0% | 0.0% | 100.0% |
| 16. We are trained to recognize that patients don't understand. | 62.5% | 12.5% | 12.5% | 0.0% | 12.5% | 100.0% |
| 17. We offer and provide interpreters. | 0.0% | 12.5% | 87.5% | 0.0% | 0.0% | 100.0% |
| 18. Pharmacy's leadership is committed to health literacy. | 25.0% | 12.5% | 50.0% | 0.0% | 12.5% | 100.0% |
| 19. We have a space that provides privacy. | 0.0% | 25.0% | 75.0% | 0.0% | 0.0% | 100.0% |
| 20. If a patient asks to speak with the pharmacist, we offer counseling on the following topics: | ||||||
| a) name of medication | 0.0% | 0.0% | 100.0% | 0.0% | 0.0% | 100.0% |
| b) purpose of medication | 0.0% | 0.0% | 100.0% | 0.0% | 0.0% | 100.0% |
| c) dose form, route of administration, duration of therapy | 0.0% | 12.5% | 87.5% | 0.0% | 0.0% | 100.0% |
| d) special directions/precautions for preparation, administration | 0.0% | 0.0% | 100.0% | 0.0% | 0.0% | 100.0% |
| e) common side effects, interactions, contraindications and what patient should do | 0.0% | 12.5% | 87.5% | 0.0% | 0.0% | 100.0% |
| f) techniques for self-monitoring | 12.5% | 50.0% | 25.0% | 0.0% | 12.5% | 100.0% |
| g) proper storage | 25.0% | 37.5% | 37.5% | 0.0% | 0.0% | 100.0% |
| h) refill information | 12.5% | 50.0% | 37.5% | 0.0% | 0.0% | 100.0% |
| i) action to be taken in case of missed dose | 0.0% | 75.0% | 12.5% | 0.0% | 12.5% | 100.0% |
| 21. I have received training on the following clear verbal communication techniques: | ||||||
| a) how to effectively organize the info given to patients | 25.0% | 37.5% | 25.0% | 0.0% | 12.5% | 100.0% |
| b) how to communicate using simple language | 25.0% | 25.0% | 37.5% | 0.0% | 12.5% | 100.0% |
| c) how to check for understanding | 12.5% | 37.5% | 37.5% | 0.0% | 12.5% | 100.0% |
| 22. I am confident that I can effectively educate patients about medicines and diseases when: | ||||||
| a) time is limited | 0.0% | 25.0% | 50.0% | 0.0% | 25.0% | 100.0% |
| b) patient has many medications | 0.0% | 12.5% | 62.5% | 0.0% | 25.0% | 100.0% |
| c) patient has many new prescriptions | 0.0% | 12.5% | 62.5% | 0.0% | 25.0% | 100.0% |
| d) many changes in dosage | 0.0% | 0.0% | 75.0% | 0.0% | 25.0% | 100.0% |
| e) patient has limited literacy skills | 0.0% | 50.0% | 25.0% | 0.0% | 25.0% | 100.0% |
| f) patient is in a rush | 12.5% | 50.0% | 12.5% | 0.0% | 25.0% | 100.0% |
| g) patient asks a lot of questions | 0.0% | 25.0% | 50.0% | 0.0% | 25.0% | 100.0% |
| h) patient is angry at pharmacy staff | 12.5% | 75.0% | 0.0% | 0.0% | 12.5% | 100.0% |
| i) patient is new to the pharmacy | 0.0% | 12.5% | 62.5% | 0.0% | 25.0% | 100.0% |
| j) patient does not understand how to pay for their medication | 0.0% | 37.5% | 37.5% | 12.5% | 12.5% | 100.0% |
| k) patient can't afford their medication | 12.5% | 25.0% | 37.5% | 0.0% | 25.0% | 100.0% |
| l) patient appears noncompliant | 0.0% | 25.0% | 50.0% | 0.0% | 25.0% | 100.0% |
| m) patient does not speak English proficiently | 0.0% | 25.0% | 50.0% | 0.0% | 25.0% | 100.0% |
| III. Sensitivity to Literacy | ||||||
| 23. Staff/volunteers are available to help pts fill out forms. | 0.0% | 37.5% | 50.0% | 0.0% | 12.5% | 100.0% |
| 24. We identify and understand the literacy skills a patient must have to use our services. | 50.0% | 12.5% | 25.0% | 0.0% | 12.5% | 100.0% |
| 25. We regularly obtain verbal or written feedback about the quality/effectiveness of services. | 25.0% | 62.5% | 12.5% | 0.0% | 0.0% | 100.0% |
| 26. Pharmacy policies support activities/resources accessibility to low literacy patients. | 25.0% | 37.5% | 12.5% | 12.5% | 12.5% | 100.0% |
| 27. We are confident that we effectively promote our pharmacy services to patients of all levels. | 37.5% | 37.5% | 12.5% | 0.0% | 12.5% | 100.0% |
| 28. All staff members are aware of certain behaviors that may indicate literacy problems. | 25.0% | 50.0% | 12.5% | 0.0% | 12.5% | 100.0% |
| 29. Our staff/leadership has received awareness and sensitivity training about literacy issues. | 50.0% | 37.5% | 0.0% | 0.0% | 12.5% | 100.0% |
| 30. Our staff knows about the literary resources in our community. | 87.5% | 0.0% | 0.0% | 0.0% | 12.5% | 100.0% |
1 = This is something the pharmacy is not doing; 2 = Our pharmacy is doing this but could make some improvements; 3 = Our pharmacy is doing this well.
