The Manitoba Institute for Patient Safety launched "It's Safe to Ask" in January 2007. The communication and health literacy initiative is aimed at Manitoba's vulnerable populations and their primary care providers. Phase 1 includes a poster and brochure for patients and a toolkit for providers/organizations, pilot tested in six sites in Manitoba. Posters will serve as a symbol that dialogue is encouraged. Tools, available in 15 languages, provide patients and family members with three key questions to ask in healthcare interactions, tips on how to ask questions, and room for notes and listing of medications. The initiative will promote involvement in healthcare by patients, stronger communication between patient and provider, and reduction of risk for adverse events. "It's Safe to Ask" has been implemented in over 65 sites across Manitoba. A formal evaluation is underway. Phase 2 and 3 will enhance key tools and include interventions with specific populations.

What Is the Problem?

Patients who visit the doctor expect to leave knowing what their health problem is, what they need to do about it and why. But for patients with low health literacy, this is rarely the case. The 2003 Adult Literacy and Life Skills Survey found that 42% of Canadian adults lacked sufficient literacy skills to cope with the demands of life and work in our society ("Literacy and Health in Canada" 2006). Over 43% of American adults are unable to read, understand and act on basic health information (Institute of Medicine Committee on Health Literacy 2004; Schwartzberg 2005). Healthcare information and instructions that patients receive may be complex, illegible, poorly designed, poorly written and delivered in a way that does not match the patients' literacy and language levels (Baker 2005; Rudd 2005).  

Patients with low health literacy have less knowledge about their health problems (Weiss et al. 2005) and are more likely to be confused or inadequately informed about their condition and the processes of care needed to manage it (Shillinger et al. 2004). They have more difficulty identifying their medication, describing their treatment (Wolf et al. 2005) and reading medication labels, and thus may take medications incorrectly (Perrin 1998). Healthcare professionals often make incorrect assumptions about individuals' ability to read, ask questions and comprehend health information (Institute of Medicine Committee on Health Literacy 2004). Fear, embarrassment, shame and limited skills keep patients with low health literacy from asking important questions of healthcare providers and clarifying the answers (Speros 2005). When low health literacy is invisible, communication is not adjusted to meet the level of the patients (Safer and Keenan 2005).

Although frequently overlooked, low health literacy is a serious threat to patient safety, promoting misunderstandings, miscommunication, errors, increased hospital admissions, longer hospitalizations, poor health outcomes and higher healthcare costs (Baker 2005; Rudd 2005; Schwartzberg 2006; Weiss et al. 2005; Wolf et al. 2005). Low health literacy increases hospital admission rates by up to 30% and may cost as much as US$73 billion annually in the United States (Institute of Medicine Committee on Health Literacy 2004).  

What Do We Need to Do?

Presenting health information in clear, plain language, ensuring written patient materials are presented at no higher than a grade five reading level (Mayer and Villaire 2004; Safer and Keenan 2005) and supplementing text with graphics, cartoons and photos (Baker 2005; Davis and Wolf 2004; Delp and Jones 1996; Kickbusch 2001; Rudd 2005; Schwartzberg 2005) are steps to improving health literacy. However, better educational materials for patients need to correspond with improved communication between professionals and their patients. A clear conversation in the doctor's office, hospital or pharmacy is the only way to confirm that patients understand information they have received, know how to act on it and understand why they should do so. Patients need to ask the questions that will provide them with necessary information; healthcare providers need to recognize the signs of low health literacy and adjust their communication accordingly (Hixon 2004; Kleinbeck 2005).  

Why Do We Need to Do This?

Increasingly, patients are asked to engage in decision-making, information seeking and monitoring of their own health (Institute of Medicine Committee on Health Literacy 2004). Low health literacy is most common among the elderly, minorities, persons with limited English proficiency, immigrants and those with low incomes (Baker 2005; Faguy 2004). Seniors are particularly likely to have low health literacy; they are also more frequent users of the healthcare system and take more medications (Centre for Literacy 2001). Many seniors overestimate their literacy skills (Centre for Literacy for Quebec 2001) and are reluctant to ask for health information because of their respect for the doctor-patient relationship and their socialization patterns; the potential for medication errors in this group is great. Health literacy is also a particular concern for Aboriginal Manitobans, 45-70% of whom have less than a grade nine education (Statistics Canada 2001). As treatment regimes become more complex, with many patients managing their health at home (via multiple medications, inhalers or devices to monitor blood sugar), low health literacy is an increasing problem.

The Canadian Council on Health Services Accreditation (CCHSA) includes communication and patient involvement as one of 21 required organizational practices for patient safety in their organizational accreditation surveys. As an example of an initiative that corresponds with this required organizational practice, CCHSA has included links to It's Safe to Ask.    

Introducing It's Safe to Ask

US-based Partnership for Clear Health Communication developed Ask Me 3 to encourage patients to ask three basic questions about their healthcare. Preliminary research showed that where Ask Me 3 was implemented, patients were indeed more likely to ask three simple questions about their healthcare (Allison-Ottey 2006).

It's Safe to Ask is a Manitoba Institute for Patient Safety (MIPS) initiative, patterned on Ask Me 3, that encourages patients to ask three simple questions:

  1. What is my health problem?
  2. What do I need to do?
  3. Why do I need to do this?

The initiative's goals are to raise awareness of health literacy issues, improve health literacy and enhance communication between professionals and patients. It's Safe to Ask tools include patient brochures and display posters, with information presented at a grade four reading level. Materials are available for free at www.safetoask.ca in 15 languages: Amharic, Arabic, Chinese, Cree, English, Eritrean, French, German, Korean, Ojibwa, Oji-Cree, Punjabi, Russian, Spanish and Tagalog. All materials were reviewed by literacy experts and focus tested with community user groups. MIPS also worked with healthcare providers to create tools for them, including information on low health literacy and its impact on patients' experiences, strategies for effective communication with patients and families and an implementation guide.

A pilot test period was held from June to November 2006 in six healthcare settings across Manitoba: an inner-city community clinic, a French healthcare centre, three community pharmacies and a Labour, Delivery, Recovery and Post Partum ward at a teaching hospital. Participants' feedback was used to refine and improve the initiative. Leading up to the province-wide launch on January 9, 2007, and coinciding with Canadian Patient Safety Week 2006, 19,000 pharmacists, nurses and physicians across Manitoba received It's Safe to Ask information and a poster and brochure. The official public launch began a four-month public awareness campaign that included billboards in Winnipeg and surrounding urban and rural areas, Winnipeg transit bus ads, public service announcements (in six languages), community newspaper articles and a dedicated website, www.safetoask.ca. Twenty-two sites in Winnipeg and various sites across other Regional Health Authorities were early implementers of It's Safe to Ask. There have been close to 140,000 hits to the website since the launch.

A formal evaluation of It's Safe to Ask is under way with funding from the Manitoba Medical Services Foundation and the Winnipeg Foundation. The evaluation focuses on assessing awareness, examining implementation and learning about ways in which patients and providers are using Its Safe to Ask across Manitoba. Results are expected in early 2008.  

Well over 80 Manitoba sites have requested tools for patients and healthcare providers, and each will determine the best possible way to integrate the initiative at their site. Early learning indicates that a planned, sustained effort, with continued education and assistance by site champions and expressed support from senior leadership, is key to the successful implementation of It's Safe to Ask. At any site, there needs to be a person devoted to quality improvement and patient safety who "owns" It's Safe to Ask - this person communicates with existing and new staff about its use and benefits, replenishes brochures and helps to integrate It's Safe to Ask into existing processes, such as discharge planning. Making any new initiative "the way we do business here" is difficult work, and inviting patients to be involved in this way needs ongoing, explicit support from executives, directors and managers. Ongoing discussion among staff within teams about how to work with patients with low health literacy is important. If a site loses its "champion," the initiative can become very passive, with little noticeable change in patient behaviour. Posters need to be kept in good repair and in view of both patients and staff. Participating organizations should add to their website a link to the It's Safe to Ask website.

Further research will explore the relationship between the use of It's Safe to Ask and increased patient satisfaction, improved health literacy and better health outcomes. The next phase of It's Safe to Ask is under way and involves MIPS, the Manitoba Society of Pharmacists and the Manitoba Pharmaceutical Association. They are working to develop, focus test and distribute a patient tool for medication safety, including a "how to and why" video for providers and patients. The tool is based on the best practice of medication reconciliation (Safer Healthcare Now!), the principles of It's Safe to Ask and the Emergency Response Information Kit initiative.


It's Safe to Ask is a step toward a healthcare culture that is open and welcoming of patient and family involvement. By providing patients with ongoing support and tools to help them request the information they need, and by continuing to offer supportive education to healthcare providers, It's Safe to Ask promises to have a significant impact on patient safety and satisfaction in Manitoba.  

About the Author

Jan Byrd, MA, is the manager of the Patient Experience and Quality Department at St. Boniface General Hospital in Winnipeg, Manitoba. She was the project lead for It's Safe to Ask in her position at the Manitoba Institute for Patient Safety prior to her appointment at St. Boniface General Hospital.

Laurie Thompson, RN, MN, is the executive director of the Manitoba Institute for Patient Safety, a not-for-profit agency that promotes, coordinates and facilitates activities that have a positive impact on patient safety throughout Manitoba while enhancing the quality of healthcare for Manitobans. You can reach Ms. Thompson by e-mail at LThompson@mbips.ca.


The authors would like to thank the following for their funding support for phase 1 of It's Safe to Ask: AstraZeneca, the Winnipeg Foundation, Canadian Patient Safety Institute, the College of Physicians and Surgeons of Manitoba and the Manitoba Medical Services Foundation.


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