Teach-back, Closing the Loop, Ask-Tell-Ask
Evidence-based communication strategies that have similarities to Ask Build Check
This page provides a description of three communication strategies, Teach-back, Closing the Loop and Ask-Tell-Ask, and discusses the relationship between these and the Ask Build Check model. It also describes the evidence and rationale for using the Ask Build Check model.
The purpose of Ask Build Check
The purpose of Ask Build Check is to make sure everyone understands what happens in a healthcare appointment.
Comprehension starts with prior knowledge. Schema theory explains how people use this prior knowledge. It explains how knowledge is organised as sets of information and then brought to mind when new information comes in.
Schema theory means that people relate all new information to what they already know or have experienced. There are lots of different schema being used in a healthcare appointment:
knowledge about the person’s health
knowledge about health generally
knowledge about what happens during an appointment
knowledge about specific areas, eg, medical words, medicines, different parts of the health sector and so on.
The person’s schema are activated in Step 1 Ask when the healthcare provider asks the person what they know, do, think and believe about their health or specific condition.
Step 1 Ask helps people bring to mind everything they already know about a topic and prepares them to receive new information to add to their schema (Step 2 Build).
If a person has very little knowledge about a health condition, new information that isn’t linked to their schema will be difficult to understand.
Conversely, if a person has a lot of knowledge about a health condition, they are much more likely to understand and act on new information that connects to what they already know.
Step 1 Ask has real benefit for the healthcare provider. Finding out what a person knows enables healthcare providers to link new knowledge to existing schema. If a person knows a lot, then the healthcare provider only has to add the information the person doesn’t know – saving time and showing respect.
If the person doesn’t know very much, eg, as with a new diagnosis, the healthcare provider makes decisions about what information the person needs to know first and what can be added later.
This prevents the person being overwhelmed and as a result not taking on any knowledge at all.
The final step (Step 3 Check) is when the healthcare provider checks they have been clear, and the new information has been added to the person’s existing knowledge.
There are a number of other evidence-based communication strategies developed in the United States that have similarities with Ask Build Check:
Closing the Loop
Teach-back is a communication strategy developed as part of patient-centred care.
Specifically, Teach-back was developed to address widespread research that showed people recalled between 20–60% of what they discussed with their healthcare providers.
Teach-back is described as a way to check patient understanding.
Teach-back involves the healthcare provider asking the person to repeat back what they thought was said.
“We talked about how to take your new medicine. Would you mind saying it back to me so that I know I was clear?”
In terms of the Ask Build Check model, Teach-back covers the Check step.
However, there are limitations if healthcare providers just use Teach-back and not the whole Ask Build Check model.
For example, people may be able to recall what the healthcare provider said and ‘teach this back’, but because the new information may not make any sense to their existing schema, they are not likely to act on the information.
Closing the Loop
Closing the Loop is a communication strategy that has been adapted for use in health care.
Closing the Loop was initially developed as a way of confirming instructions, particularly in high-risk situations.
In health literacy, the strategy has been further adapted for a patient education session.
Schillinger D, Piette J, Grumbach K, et al. Closing the Loop: Physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90. doi:10.1001/archinte.163.1.83
There are a number of limitations with Closing the Loop, including that:
recall does not guarantee comprehension (eg, understanding how to take medicine as prescribed)
the process is inefficient in that the person’s knowledge and beliefs may only be identified later on during the Closing the Loop process.
The Ask Build Check model identifies the person’s knowledge and beliefs as Step 1 Ask, which enables the healthcare provider to seek more information, and in Step 2 Build to adjust and/or provide more information to work with the person’s existing knowledge and beliefs.
Ask-Tell-Ask is a communication strategy developed for use in healthcare settings, especially by health coaches.
Ask-Tell-Ask acts as a simple reminder to increase the likelihood that the person is more likely to take on the information given by the healthcare provider.
Ask can be done in two ways:
Ask for permission to give information or advice – this is respectful.
Ask what the person knows or wants to know – so that the healthcare provider can start contextualising the information to the person’s interest. This has some similarities (as well as differences) to the approach in Step 1 Ask.
Tell is about the healthcare provider giving their message in plain language relevant to the person.
Ask – again there are two options:
Ask what they think of the information.
Ask a Teach-back question.
There are limitations to Ask-Tell-Ask.
Only asking permission to share information increases the likelihood that the information or advice the healthcare provider gives will not match the person’s schema (what they already think, know, do and believe) and therefore may not be acted on.
Asking people what they already know or want to know, and adjusting your information or advice as they tell you, limits listening skills. It is hard to actively listen to understand someone when you are thinking about what you are going to say next. This is called listening to reply rather than listening to understand.
Telling is not usually an appropriate strategy unless it is an emergency. People are much more likely to follow advice or act on information when they are involved in the building of the knowledge so it makes sense based on what they already think, know, do and believe.
Asking what people think of the information could mean that the person responds in a way that is based on what they think you are expecting, rather than telling you that the information or advice doesn’t make sense or is impossible to act on.
Asking a Teach-back question if you haven’t already found out the person’s schema shows the person can recall the information or advice. It does not guarantee that the person understood or will act on the information or advice.
For example, a person may be able to easily repeat back the instructions for taking their new medicine. However, that does not mean the person is going to take the medicines.
Instead, using Step 1 Ask first, the healthcare provider might find out that members of the person’s family have taken this medicine previously and experienced side effects.
As a result, the healthcare provider might decide to:
prescribe a different medicine
explain why the person’s family members might have had side effects, eg, taking other medicines
develop a plan with the person about what to do if they experience side effects.