Saying It Clearly

For more information on these topics, select one of the following:

• Key Principles.
• Writing Well.
• Producing Readable Charts.
• Creating Meaningful Labels and Definitions.

Sponsors should note that this section addresses the presentation of written materials, whether delivered on paper or electronically. This is not meant to imply that quality information can only be communicated in writing; it merely reflects the current state of the art.

Key Principles

• Know Your Audience.
• Be Clear About the Purpose of the Report.
• Create a Structure that Reinforces the Purpose.
• Be Consistent.

Know Your Audience

Information is clear if the audience for that information can understand it. The implication of this statement is that there is no one right way to present information on health care quality; there is only a way that works for your audience. This suggests three important guidelines for creating an effective performance report:

• Learn About Your Audience.
• Segment Your Audience.
• Ask for Feedback.

Learn About Your Audience

There are three things you need to learn about your audience.

1. Who are they, and what do they want and need to know about health care quality?

Take the time to profile your audience. When developing a performance report, you might want to consider Important Characteristics of Your Audience.

Ask your audience, as well as those who know them well, about their concerns about quality, their need for health care services, and their current state of knowledge about how health care is delivered.

To learn more, select Where to Get Information About Your Audience. 

2. Can they read and understand information in a performance report?

Before you produce a complicated document on health care quality, find out how literate your audience is in the English language. This will determine not only how you present information, but also how much information you can present. In addition, if they are not very literate in English, are they literate in other languages? There may be an opportunity to provide translated information to reach more readers.

For more information on literacy, go to the National Institute for Literacy's Frequently Asked Questions. 

For information about the development of Federal standards for culturally and linguistically appropriate services, go to Assuring Cultural Competence in Health Care. 

For some audiences, the question is not whether they can read but whether they want to receive information in this way. While written information works well for some segments of the population, others prefer to get information in person or through the mass media (television and radio).

For more information on mass media, go to Reaching People Where They Are.

3. How will they perceive the information?

Finally, remember that people do not necessarily perceive information in the way in which it was intended. Perceptions are colored by people's life experiences, culture, and personal values and expectations. While it is not possible to account for individual differences, your report should show an awareness of and respect for the variety of cultures represented in your audience.

The United States has one of the most diverse populations in the world; your audience may or may not reflect that diversity. To ensure that your message comes across to a mixed audience, you need to provide materials that are culturally appropriate, which means that they reflect an understanding of and respect for the various cultural norms of your audience, including their assumptions, values, and expectations.

There are many ways to make your materials culturally appropriate. One simple technique is to include in the report photos and illustrations that reflect the demographics, physical appearance, behavior, and cultural elements of your audience. On a more sophisticated level, you can also incorporate your understanding of your audience's culture into the way you phrase ideas, the choices you make in terms of data and presentations, and the tone you use to motivate the reader.

Segment Your Audience.

It is also useful to consider which of these audiences you are most interested in reaching with your information.

Which is the primary audience?

Seniors, for instance, may be the primary audience for your information on the quality of Medicare plans.

Which is the secondary audience?

A secondary audience may influence the decisions of the primary audience by providing assistance or advice. For Medicare, a secondary audience may be the adult children of seniors and the insurance counseling services available around the country.

Which is the most significant audience?

Significance determines which audience you think about the most when you write and design your information. The most significant audience could be the one that represents the majority of readers, the most motivated readers, the most needy readers, or the readers that wield the most influence. (For several years, performance reports were written for employers because they were thought to have the greatest impact on the market.) If, for example, you believe that seniors will not be able to understand and interpret the data on their own, information intermediaries (such as counselors in senior centers) may be the most significant audience.

Ask for Feedback

No matter how hard you try, you will not be able to predict how your audience will respond to the information you give them. Let them tell you what's appropriate, what's working well, and what isn't. This kind of evaluation should occur both during the development of your report as well as after its distribution. 

Be Clear About the Purpose of the Report

People don't read information on health care quality for entertainment. They look at it because it may teach them something useful and, more importantly, help them do something they value: pick a health care organization that meets their needs.

But many report card sponsors make the same mistake, which is to imply the purpose of the information rather than making it explicit. For instance, many performance reports say that they were created to help the reader "become an active, informed consumer." What does that really mean? The document should tell readers what they can do, not what they can "be".

A related problem is the use of indirect language that presumes that the reader will easily make the leap to an important implication. For instance, some reports tell the reader that health plans affect the quality of care they get, but don't spell out what this has to do with the information in the report (i.e., that the readers can use the information to help choose a plan that performs well in the areas they care about most).

As you create information on health care quality, you need to be thinking about the reasons you want to provide the information and supporting those functions throughout the document. The purpose of a quality report could include any combination of the following:

• To introduce new information.
• To build awareness or interest.
• To motivate the reader to learn more.
• To spur action.

Whatever objectives you choose, they must be clear to you and to the reader.

Create a Structure that Reinforces the Purpose

The overall structure of the document (whether paper or electronic) should reinforce the overall point of the materials; for example, if the purpose is to help people make an informed decision, you might want to organize the report as a series of steps that show how to insert information on quality into the decision-making process.

Similarly, the structure (and contents) of each page should support the function of that page. As you look at each page, think about what it is intended to do and whether the sequencing of information is clear (e.g., read this text, look at that table, then circle the organizations with the highest scores).

It is particularly important for each page to stand on its own because your audience is unlikely to read a performance report from start to finish. Readers may start anywhere, flipping around (or surfing) until they find a page that seems both interesting and manageable. As a result, you'll want to compose each page so that it is approachable (i.e., appealing and understandable) and helps the reader get oriented in the document.

Be Consistent

Quality information can be very confusing. To make the document easier for your audience to digest, be consistent in your use of the following:

• Specific Words and Phrases.
• Colors.
• Design Elements.
• Tone.

Define terms clearly and use them in the same way throughout the text. For example, don't discuss "measures of experience" in the introduction, then use only the term "satisfaction" in the chart. 

Colors

Colors are a powerful tool for attracting the reader's attention, highlighting patterns, and helping the reader find specific information. When you don't apply colors in a consistent way, you risk confusing the reader, who will likely assume that the same color always means the same thing. For instance, if you use blue for the symbols that indicate the best performance, you should not then use blue as the color for the segment of a bar that represents poor performance. 

Design Elements

Design elements include such things as photos, drawings, icons, lines and arrows, page headers, and page numbers. Font and type size are also aspects of design. The importance of choosing these elements carefully and using them consistently cannot be overstated. Readers who can't find what they are looking for or interpret what's on the page will give up, never getting to the information you want them to see. Also, people are easily distracted by a busy design, especially if it changes from page to page so that they have to make an effort each time to decipher what's in front of them.

Tone

Tone refers to the attitude implied by the language in the document. For instance, a chatty tone suggests that the document is intended to be friendly and helpful, while a more formal tone may make the document seem more serious and important. Whatever tone you choose for your audience, confirm that the "voice" of your document is consistent throughout; some readers may skip critical material that feels different (e.g., a very academic-sounding explanation of measures in an otherwise chatty report), assuming that it doesn't apply to them.

Writing Well

Good writing is an art, but it is also a skill that you can learn. Since language and writing style play a large role in determine whether anyone bothers to continue past the cover, it can be helpful to review the characteristics of a well-written performance report and incorporate them into your project.

• Keep It Short.
• Make It "Skimmable."
• Use Devices that Engage the Reader.
• Use Accessible Language.
• Write Text that People Can Understand.
• Be Sensitive to How Words May Be Interpreted.
• Use Active Language.
• Help the Reader Navigate the Page.

You may also want to consider working with a professional writer or editor who is experienced in communicating with your audience and (ideally) has some knowledge of the topic of health care quality. However, it is important to remain "hands-on" in order to ensure that the writer doesn't miss any nuances that may be important to your audience.

Keep It Short

Generally speaking, people do not read any more than they have to read. To improve the odds that people actually read what you have written, be as concise and clear as possible, and don't write much.

A representative of one experienced sponsor noted that since people tend to turn immediately to the displays of information, they chose to limit the introductory and explanatory material in the front of the publication to the "bare minimum"—just enough to answer any questions the reader might have after looking at the data.

Other experts suggest that people will read introductory material if they perceive a payoff to doing so, i.e., that they will obtain valuable information they can use in some way. For this to happen, the reader has to be able to read through the material quickly and easily.

Make It "Skimmable"

While some readers will read a report from beginning to end, many do not move systematically through materials. Through one-on-one interviews, researchers have found that some people flip through quality reports in search of useful information, stopping to read things that seem interesting. If this task is too daunting for such readers, the document is unlikely to achieve its purpose.

To make it easier for people to scan the document, use meaningful headlines that tell a story. That is, each section and subsection of your report should have a header that summarizes its contents, like a newspaper headline. This allows the reader to find what they are looking for and obtain compelling information without having to read everything. Contrast this approach to the common use of labels, which don't convey useful information.

Label: Health Plans and Referrals 
Headline: Health Plans Influence Your Doctor's Referrals to Specialists

Another way to help the reader skim is to use bulleted or numbered lists. Lists are a useful tool for making details easier to read (such as the measures included in a given category) and for drawing attention to certain information (such as the steps reader should follow to factor quality data into their decisions about health care organizations). Numbered lists are particularly helpful for less capable readers, who can use the numbers to follow the order of information, organize the information, and refer back to the text. Lists of any kind also break up the flow of text on the page, creating "white space" that makes the page easier on the eye.

Use Devices that Engage the Reader

To capture the attention of your audience, you may want to use one of a number of techniques that can help to draw them in, including:

Questions and Answers

For example:

• How do health plans differ?
• How do health plans affect quality of care?

Common Myths

For example:

• Myth: Health plans are all the same.
• Myth: Health plans can't influence what my doctor does.

True or False Statements

For example:

• Your health plan can help your physician provide you with high-quality care. True or false?
• Quality of care doesn't vary much across health plans. True or false?

These strategies help to engage readers by stimulating their curiosity and, especially in the case of "true or false" statements, making the learning process more interactive. Like headlines, these devices enable the reader to focus on the issues of greatest interest. Like lists, they also break up the flow of text so that it is less overwhelming.

Another approach is to use vignettes and anecdotes that people can relate to. Educational materials often rely on stories to help people understand things like how to use the health care system and how to weigh their options. This is an effective method because many people come from cultures in which stories play a key role in the transmission of traditions and knowledge from generation to generation. To date, sponsors and researchers have not figured out how to use anecdotes to communicate data on performance, but that does not mean it's not a good idea.  

Use Accessible Language

Accessibility is a function of many factors, includes words, sentence structure, the relevance of issues, and cultural perspective. When creating and reviewing the text of a performance report, consider the following issues:

• Familiarity of Words.
• Quantity of Words.
• Familiarity of Sentence Structure.
• Relevance of Issues.
• Cultural Perspective.

Familiarity of Words

Are you using words that are known to the reader? Even highly literate readers may be unfamiliar with many of the terms common in the health care industry and in the field of quality measurement. If you must use jargon, be sure to define it and explain the term's implications for the reader. For example, to explain accreditation, you can say:

• Accreditation means that a National, independent organization has approved the quality-related structures, processes and performance of a health plan.
• Accreditation is like a stamp of approval, letting you know that the health plan meets National standards related to quality.

Rather than relegating them to a glossary, provide these definitions wherever you use the terms. Many consumers—and especially low-level readers—will not bother referring to a glossary.

At the same time, keep in mind that health care quality reports offer a forum for educating consumers about terms they need to know. Rather than emphasizing the simplest way to describe something, some experts suggest that sponsors use technical or clinical terms with easy-to-understand definitions so that the reader can learn over time.

Select for a list of Unfamiliar Terms Found in Many Report Cards that are not universally understood.

For articles on this subject, go to What Research Tells Us: Relevant Studies.

Quantity of Words

Are you using too many words? Experts recommend that you identify what you have to say that is most critical and omit any unnecessary words. Even a sentence with simple, one or two syllable words can be inaccessible if it takes too many words to make the point.

Familiarity of Sentence Structure

Are you writing sentences that readers can interpret easily? In research conducted for the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS), RAND found that readers tend to rely on the basic strategy of picking out the subject, verb, and object in order to interpret complex sentences. When that task is too hard, all but the most motivated readers will give up.

Also, readers prefer the active voice to the passive voice.

Relevance of Issues

Are the terms and issues in the report relevant to your intended audience? In the past, many report cards were inaccessible because they addressed issues that potential readers didn't care about; they were not interested in learning what they would need to know to understand and use the information.

Cultural Perspective

Are you talking about concerns that may be "foreign" to a specific culture? For example, some cultures are not comfortable with the idea of questioning the authority of medical professionals; for these people, information on the responsiveness of physicians would not be accessible because it would not fit with their view of the world.

Write Text that People Can Understand

One critical problem with most reports on health care quality is that people cannot easily read and understand the material. Generally speaking, the reading level of health care information exceeds the abilities of the majority of Americans.

Select links below to learn more about:

• Literacy in America.
• The Problem with Today's Report Cards.
• How to Make Reports Easier to Understand.

For articles on this topic, select Performance Reports Exceed Our Capabilities.

Literacy in America

On average, Americans have about 12.5 years of education. However, people read several grades lower than their highest educational achievement, so the average reading level for adult Americans is actually somewhere around eighth or ninth grade. Literacy skills vary widely, so you cannot assume that materials that work in one place or situation will be acceptable in another. They also vary by age and socioeconomic status: people in Medicaid programs tend to read at the fifth grade level or lower and literacy skills for those 65 and older are substantially lower than those for the population as a whole.

In the National Adult Literacy Survey (NALS), which reports functional literacy in five levels, nearly half of the adults scored in the lowest two levels of literacy. However, 44 percent of people 65 and older scored in the lowest level, and over two thirds of welfare recipients scored in the lowest two levels. According to researchers, the materials in quality reports typically require literacy skills at Level 5.

Select for information on the findings of the National Adult Literacy Survey.

The Problem with Today's Report Cards

Most existing information on health care quality exceeds the reading capabilities of the average American. Studies of patient education materials have found that many are written at a tenth grade level or higher. In fact,an analysis of seven State report cards found grade levels ranging from ninth grade to third-year college.

This mismatch between the difficulty of report cards and the capabilities of consumers suggests that a large number of American adults would have to struggle to read and understand anything other than the simplest print material. This would not be quite as big a problem if people sought help in interpreting health care information, but the reality is that low-literate people tend to hide their problems or simply don't access and use print materials. Moreover, they are usually very successful at doing so. As a result, you can't assume that people will let you know if they don't understand the information you provide.

How to Make Reports Easier to Understand

To help your audience understand your report, you may want to try a combination of the following strategies:

• Write text at a grade level that suits the abilities of your audience.
• Test the text with consumers.
• Write in "plain English."
• Cultivate "information intermediaries" who can interpret the information for your audience.
• Focus on the fundamentals of quality health care.
• Pay attention to the design.

Write text at a grade level that suits the abilities of your audience.

Reading experts recommend two approaches to ensure that the materials you prepare are appropriate for the reading skills of your audience:

• Perform a test that measures the difficulty of written materials. These tests use formulas to estimate reading grade level. However, it is important to recognize that the tests focus narrowly on the difficulty of words and sentences, which is just one aspect of reading. They do not capture many other things that influence how readable your materials actually are, such as supporting context, logic, the linking of ideas, cultural appropriateness, and writing style. Also, since they are based on simple calculations, they do not reflect the ability of readers to find meaning in what they read, drawing from their life experience and their familiarity with the subject.

To learn more about the available tests, select Measuring Reading Difficulty.

Perhaps the most important thing to remember about these scores is that they are not precise measures of how a reader will comprehend a passage but are general indicators of the difficulty of the words and sentences in the passage. A score from one of these formulas basically indicates a range of grade levels: the specified grade level plus or minus 1.5 levels. So they are useful for getting a general sense of the difficulty of your materials:

Indication of Grade Levels

If material tests at:	Consider it to be:
Fourth to sixth grade	Easy to read
Seventh to ninth grade	Average difficulty
Above ninth grade	Difficult

Select for Text Version.

• Estimate the reading skills of your audience. There are two ways to estimate the reading level of your audience. The first is based on research that found that reading level is usually three to five years below the highest grade that a person has completed. So if you have some idea how much schooling is typical for your audience, you can estimate their reading level. The second approach relies on data from the National Adult Literacy Survey (NALS), which shows literacy levels for people of different ages, races/ethnicity, and health status. You can use the data from this survey to estimate a reading level based on the demographics of your audience.

Test the text with consumers.

While readability formulas and estimates can offer some insight, it is best to test materials with consumer groups. Let them tell you whether they had any trouble reading and understanding the text and how they interpreted it. Using one-on-one interviews, you can learn how well people understand what they are reading and where you need to make revisions to simplify or clarify your materials. Focus groups and cognitive interviews can help you get a better sense of the kind of language and tone that will make it easier for your audience to understand your report.

The key to successful testing is to do it early and, if budgets and schedules permit, often. This approach enables you to make necessary changes while the report is still in development. Select to learn more about testing materials with your audience.

For more information on these approaches, go to Techniques for Testing and Evaluation.

Write in "plain English."

The reading grade level of your audience can help to guide your writing by encouraging you to simplify your language and sentence structure. But the process used to determine reading levels should not govern your writing style. While it may earn a "good" score for readability, text written with only short words and short sentences is very hard to read and understand. Also, language that is too simple may delete important context or distort the meaning of what you are trying to say. Finally, readers may perceive it as condescending.

To avoid the problems that arise from overemphasizing the length of words and sentences, reading experts suggest that sponsors use plain English, also known as plain language. Plain English has the following characteristics:

• A writing style that is clear, simple, and conversational.
• Good organization of key points.
• A logical sequence of information.

Select for more information on the Plain English Network.

Cultivate "information intermediaries" who can interpret the information for your audience.

Experts have suggested that it may not be possible to explain some of the concepts in a performance report at a low grade reading level (i.e., fourth to sixth grade). In that case, it may be necessary to recruit and train people who can help members of your audience understand and apply the information you provide.

Focus on the fundamentals of quality health care.

Rather than dive into a complex topic like comparative quality measures, you may want to focus on educating your audience about the more fundamental elements of quality care. For example, you could develop materials that provide basic information about such topics as how to use the health care system effectively, how to get timely access to care, how to file complaints, and how to change doctors.

Publications by the Medicare Rights Center.

Your Health Plan Handbook (PDF file, 286 KB; HTML, by The Community Service Society of New York (CSSNY).
© Copyright 1997. Community Service Society of New York. All Rights Reserved. Used with Permission.

Pay attention to the design.

Design issues, such as line length and type size, can also affect readability. Even well written materials can become difficult for the reader if the design makes them seem inaccessible.

For details, go to Designing your Report.

Be Sensitive to How Words May Be Interpreted

Your audience is likely to interpret (and misinterpret) the words and phrases you use in ways you never intended them. Here are two things you can do to avoid this problem:

Stay involved in the writing process even if you have farmed out the job to professional writers (either in-house or through a contract). The problem is that a writer who is not familiar with the issues and your audience is ill-equipped to judge what's important, explain the data, and recognize the nuances of certain words and phrases. The wrong word choice can raise suspicions about how well the sponsor understands the information as well as the health care needs of the audience. Consider the following examples:

• "Services" versus "Benefits": While you can talk about "services" for an audience with commercial coverage, Medicare beneficiaries are accustomed to hearing about their "benefits."
• "Average": Although you may use the word "average" to express a mathematical concept, people do not necessarily understand it in that way. An average score is often regarded negatively, indicating that something isn't good.
• "Must," "have to," "need to," and "should": While you may want to use these words interchangeably, each has a slightly difference emphasis. The differences are subtle, but the bottom line is that a phrase you think is neutral may not be perceived that way by some consumers.

Test your text with your audience during the development of your report. If possible, look at the results of testing that other sponsors and/or researchers have conducted with consumers.

Use Active Language

One common problem in performance reports is the use of sentences that are passive and remote. With a few exceptions (primarily academics and researchers), most people have a hard time interpreting such sentences. Sentences written in the active voice are much easier for readers to understand and turn into action. For example, one recent report card offered data "to help in estimating" rather than a more directive "to help you estimate."

Passive: The patient is referred by the doctor to a specialist.
Active: The doctor refers the patient to a specialist.

Passive: The cost is calculated by multiplying X by Y.
Active: You can estimate the cost by multiplying X by Y.

Help the Reader Navigate the Page

Since your audience is not likely to begin with the introduction and proceed page by page through the document, it is especially important to provide information throughout the document—not just in the beginning—that will help readers find their way. Such navigational aids may include colors, written instructions, and icons. For example, you may want to use a specific icon for survey-based data or a colored box for definitions. Written instructions tell the reader exactly what to do ("open the folded page") and where to go ("turn to page 8 to see scores for each measure"). In large documents, colors are especially helpful for letting people know what section of a report (or Web site) they are looking at.

Producing Readable Charts

Charts—including graphs and tables of various kinds—are the most efficient and practical way to convey a large amount of information. Visual presentations are also powerful tools for concisely making points that are hard to put into words. While other modes of communication (such as storytelling) may be more effective for some audiences, we do not yet know how to communicate quality information, and especially comparative data, without graphics.

However, while some consumers prefer a graphic presentation, others regard charts as a foreign language. Either they do not know how to read them, or they simply find the process too burdensome. Moreover, some people who do understand what they are seeing still respond negatively to charts, although that reaction can change once they get oriented. This suggests that you need to make a special effort to make your charts attractive and easy to interpret. This section offers several guidelines for making your charts as user-friendly as possible:

• Make Graphics Self-Explanatory.
• Show the Reader How to Read and Interpret the Chart.
• Avoid Abbreviations and Jargon.
• Keep Tables a Manageable Size.
• Use Principles of Good Design to Ease the Reader's Burden.

Make Graphics Self-Explanatory

Since people are unlikely to read any explanations in the front of a performance report, displays of comparative information have to be as self-explanatory as possible. That is, people should not have to work too hard to interpret them. Anything important for understanding the chart—like a legend or a definition—has to be on the same page, preferably at the top of the page or on the side (i.e., not on the bottom) so that the reader won't miss it.

The golden rule of chart design is as follows: if people need a lot of explanation to understand your graphic, there's something wrong with the graphic.

Select links below to learn more about:

• Decoding the Chart.
• Providing Self-Explanatory Symbols.
• Providing Self-Explanatory Bar Charts.

Decoding the Chart

To make a chart self-explanatory, you'll need to provide tools that enable the reader to decode the information. Titles, legends, and other explanatory information should tell your audience everything it needs to know. Here are some suggestions for making these elements of a performance report as useful as possible:

• Assume that you have to explain the meaning of everything, especially symbols and colors. Don't take anything for granted. Something that seems intuitive to you may not be obvious to your audience; for instance, a reader who is new to this country may not recognize that the colors red, yellow, and green have meaning as the colors of a stoplight.
• Create eye-catching, user-friendly legends that tell consumers how to read the chart. Make sure the legend has a prominent place on the page where the reader is sure to see it.
• Repeat these elements wherever they are needed so that the reader does not have to look somewhere else for an explanation. For instance, if you use the same kind of graph on several pages, include a legend for that graph on each of those pages.
• Use plain English in the titles and headings. If you have to use abbreviations or industry terms, explain them in words that readers will understand.
• Don't separate definitions from unfamiliar or industry terms. Put them as close as possible to whatever you're explaining. Researchers have found that readers are likely to lose their place if they have to skip over seven or more lines of text.

Providing Self-Explanatory Symbols

If you are creating a table that uses symbols to represent relative performance, the ability of consumers to understand those symbols will play a large role in determining how self-explanatory the table is.

However, a table that uses familiar symbols, possibly enhanced with colors, is much easier on readers; they either figure the symbols out by themselves or learn and remember what they mean. 

Select to access the Medicare Rights Center's Traffic Light (PDF file, 387 KB; HTML). This is an example of a table where readers can apply their understanding of the symbols to figure out what the chart is telling them.
© Copyright 1999. Medicare Rights Center. All Rights Reserved. Used with Permission.

Providing Self-Explanatory Bar Charts

In a bar chart graphic, there are several ways to make the bars more easily interpretable.

• Rather than display multiple responses, offer only the segment of the bar that is most relevant to your audience.
• Embed the explanation in the segments of the bars.
• Minimize confusion by creating a legend that mirrors the appearance of the bar graph.
• Offer a visual anchor (i.e., a point of comparison) that enables the reader to evaluate the results.

Show the Reader How to Read and Interpret the Chart

The ability to understand the format and structure of a chart, whether a table or a graph, is a school-based skill. That is, people do not intuitively know how to follow the flow of information in a table (i.e., to look up and down the columns and from left to right on the rows). Similarly, they do not necessarily know to look for a legend or to read the axes of a graph. For consumers who lack the training and experience, a chart can be very intimidating.

In your report, you must explain how to read and interpret any graphic you present. One way to do this is to refer to the chart within the text, making it clear to the reader what to look at and what to pay attention to (e.g., the difference between a plan's score and a National benchmark). If appropriate, you can also summarize the key points illustrated by the graphic (e.g., that all plans performed above the State average). Since people take in information in different ways, it is useful to repeat and reinforce key points in text and graphics.

Perhaps more importantly, you have to make each chart easy to navigate and indicate how to use navigational aids. One example of a navigational aid is a small graphic that shows the readers what to look at in the chart and how to interpret what they see. This is similar to a legend, but much more explicit.

CAHPS® 2.0 reporting template, 1999 (PDF file, 46 KB; HTML)

Avoid Abbreviations and Jargon

Sponsors often use abbreviated text in charts, usually in a well-intentioned effort to conserve space. But abbreviations (e.g., HMOs, PPOs, NCQA, JCAHO), like industry jargon (e.g., fee-for-service, affiliated providers), are not familiar to most health care consumers. If your readers cannot understand the language in the chart, they are unlikely to stick around to tackle the data or scores you are trying to present.

While you could explain the abbreviations in the text that comes before the chart, it is better to make the chart stand on its own by spelling out all the terminology in the chart itself and using words your audiences is likely to understand. One reason for this approach is that people will not read everything you put on the page, so they may miss your explanation. Another reason involves the capacity for readers to process multiple pieces of information; researchers have found that the more you make people read, the less likely they are to understand the message you are trying to convey. 

Keep Tables a Manageable Size

Anyone who has tried to understand a table that shows the benefits offered by a number of plans knows how hard it is to follow giant matrices. In a table with dozens of data points (whether numerical scores or symbols), there's simply too much information for people to look at, making it almost impossible to make comparisons and find patterns. In addition to being boring and intimidating, large tables also require too much effort to find specific pieces of information.

If you have a lot of data to present, consider breaking the information into smaller chunks, preferably in a way that has meaning for your readers. For example, rather than listing all health plans in the State in one table, create multiple tables that show only the plans available in each region or county. Or show all the clinical quality measures in one table, and the measures related to satisfaction and access in another.

Use Principles of Good Design to Ease the Reader's Burden

In addition to making your writing more readable, good design can make any chart much less of a challenge for your audience.

For some basic guidelines for chart design, go to Design Guidelines for Performance Reports.

Creating Meaningful Labels and Definitions

When drafting a report on health care quality, one of the biggest challenges for sponsors is deciding what to call measures and categories and how to define them. Testing with consumers has established that people do not understand the meaning or significance of many measures—especially ones related to clinical quality—unless sponsors provide explicit explanations. They want to know why a measure is important and what it tells them about the health care organization being measured. At the same time, people need to be able to take in the information quickly in order to decide whether it is worth their time to explore further.

This suggests that your task is to strike a balance between being concise and being thorough. Here are some suggestions for juggling these competing objectives:

• Create Labels That Mean Something to Consumers.
• Use Longer Labels If Needed to Be Clear.
• Tell Your Audience Why the Measure Is Important to Them.
• Explain What the Health Care Organization's Role Is.
• Be Explicit About What the Measure Says About the Health Care Organization.
• Explain the Source of the Information.
• Label and Define Measures in a Consistent Way.

Create Labels That Mean Something to Consumers

Instead of using technical or clinical terms or industry jargon, try to use everyday language that people understand. At the same time, think of what you're doing as an educational process; over time, consumers will want to understand the clinical terms that are relevant to them. For example:

Rather than: Mammography rate.
Use: Testing for breast cancer.

Rather than: Provider turnover.
Use: Doctors that stay with the health plan.

Rather than: Diabetic retinal exam.
Use: Eye exams for people with diabetes.

Use Longer Labels If Needed to Be Clear

Short labels may be tidier, but they can be ambiguous and easy to misinterpret. For example:

Rather than: Choice of doctor.
Use: Easy to find a doctor you are happy with.

Tell Your Audience Why the Measure Is Important to Them

Since this kind of information is not familiar to most people, you need to spell out why they should care about it as individuals as well as why it is important from a public health perspective. At the same time, acknowledge that some measures won't be relevant to all individuals. In particular, clinical quality measures only appeal to a limited number of people. Survey-based measures, on the other hand, tend to be more relevant for more people. For example, the ability to communicate well with a doctor is important to everyone. For examples, select Why Health Quality Measures Are Important.

Explain What the Health Care Organization's Role Is

This is generally more of an issue for health plans than for provider organizations, because many people don't understand how health plans affect the care they receive. For instance, you may want to explain how a health plan can influence how many women get tested for breast cancer or how many children get immunized.

Be Explicit About What the Measure Says About the Health Care Organization

Recognize that many measures don't really indicate anything general about the plan. That is, we usually don't know whether we can generalize to say that a measure is a good proxy for how well an organization provides care. It just tells you what it tells you.

Explain the Source of the Information that is in Each Measure

In testing with consumers, the National Committee for Quality Assurance (NCQA) found that the way people interpreted information depended on what they though its data source was, e.g., enrollee surveys or health plan records. For instance, some dismissed measures that appeared to come from surveys because they did not trust survey data or did not care what others thought. Based on this finding, NCQA recommends that a definition of a measure include some indication of where it came from. In report cards developed for several States, NCQA uses symbols to show which measures (and where appropriate, which categories) are based on surveys and which are based on HMO records.

Comparing the Quality of Maryland HMOs 1999 (PDF file, 105 KB; HTML) shows the source of data for each measure.
© Copyright 1999. Maryland Health Care Commission. All Rights Reserved. Used with Permission.

Consider whether to frame the label and definition in a negative way or a positive way. For instance:

Positive Frame: What percentage of patients survive?
Negative Frame: What percentage of patients die?

Positive Frame: What percentage of doctors stay in the plan?
Negative Frame: What percentage of doctors leave the plan?

Researchers are currently investigating which kind of frame is more effective with consumers. So far, the results of their testing suggest that readers perceive a negative frame as more compelling, especially if it ties into their own fears and concerns. This is consistent with the way that people react to reports in the media. However, since audiences can differ, you may want to explore the usefulness of alternative frames in securing the attention of your audience. Also, keep in mind that health care organizations may not support the use of negative frames. 

Label and Define Measures in a Consistent Way

Consistency is critical because people will use their ability to understand information in one area to help them interpret information in another area. For instance, it is confusing to mix measures in which a high rate is considered good (such as measures related to health screenings) with measures in which a low rate is good (such as provider turnover). If necessary, reword and redefine measures so that a higher rate always indicates better performance.