Purpose: Healthcare systems are increasing in complexity, and to ensure people can use the system effectively, health organizations are increasingly interested in how to take an organizational health literacy (OHL) approach. OHL is a relatively new concept, and there is little evidence about how to successfully implement organizational health literacy interventions and frameworks. This study, a literature review, aims to explore the operationalization of OHL. Design/methodology/approach: A realist literature review, using a systems lens, was undertaken to examine how and why the operationalization of OHL contributed to changes in OHL and why interventions were more effective in some contexts than others. Initial scoping was followed by a formal literature search of Medline, CINAHL plus, Web of Science, Scopus, Embase and PsychINFO for original peer-reviewed publications evaluating OHL interventions until March, 2018. Findings: The search strategy yielded 174 publications; 17 of these were included in the review. Accreditation, policy drivers, executive leadership and cultures of quality improvement provided the context for effective OHL interventions. The dominant mechanisms influencing implementation of OHL interventions included staff knowledge of OHL, internal health literacy expertise, shared responsibility and a systematic approach to implementation. Research limitations/implications: This study outlines what contexts and mechanisms are required to achieve particular outcomes in OHL operationalization. The context in which OHL implementation occurs is critical, as is the sequence of implementation. Originality/value: Health services seeking to implement OHL need to understand these mechanisms so they can successfully operationalize OHL. This study advances the concept of OHL operationalization by contributing to the theory underpinning successful implementation of OHL.