1. Preparing an organisation for electronic clinical information systems: Does culture matter? Dr Joanne Callen Senior Research Fellow Health Informatics Research and Evaluation Unit The University of Sydney j.callen@usyd.edu.au

2. 14 th October 2009HIMAA National Conference Perth 2009 Overview of presentation Organisational culture – what is it? Sub-cultures in large organisations Is there a relationship between culture and clinical information systems? Models to assist with implementing information systems

3. 14 th October 2009HIMAA National Conference Perth 2009 Background Organisational culture has been identified as a significant factor for successful implementation of clinical information systems Gosling et al. Int J Med Inf. 2003; Aarts et al. JAMIA, 2004; Callen et al. Soc Sci & Med 2007

4. 14 th October 2009HIMAA National Conference Perth 2009 What is organisational culture? “the basic pattern of shared assumptions, values and beliefs governing the way employees within an organisation think about and act on problems and opportunities” McShane & Von Glinow, 2000, p. 498

5. 14 th October 2009HIMAA National Conference Perth 2009 Subcultures Pronounced in health care organisations Based on professional, occupational, gender, functional distinctions Can reflect or differentiate organisation- wide culture Can draw values from outside (example medical sub-specialties)

6. 14 th October 2009HIMAA National Conference Perth 2009 Research study Is there a relationship between hospital sub-cultures and attitudes to, and satisfaction with, clinical information systems? Callen et al. The importance of medical and nursing sub- cultures in the implementation of clinical information systems. Methods of Information in Medicine. 2009 48(2):196-202

7. 14 th October 2009HIMAA National Conference Perth 2009 Methods Research setting  Two clinical units: Emergency Department and Haematology/ Oncology Ward  400 bed metropolitan public teaching hospital

8. 14 th October 2009HIMAA National Conference Perth 2009 Clinical information context  Computerised physician order entry system used to order and view all laboratory and radiology tests

9. 14 th October 2009HIMAA National Conference Perth 2009 Survey design Two survey instruments  Organisational culture inventory  User satisfaction survey Population (n=103) All doctors (n=42) and nurses (n=61) in two clinical units

10. 14 th October 2009HIMAA National Conference Perth 2009 Organisational culture inventory (OCI) Constructive culture work cooperatively; high motivation; teamwork Passive/defensive culture please those in authority; wait for others to act first Aggressive/defensive culture oppose new ideas; compete; appear competent and independent

11. 14 th October 2009HIMAA National Conference Perth 2009 Culture and cultural styles in OCI Constructive culture o Achievement style o Self-actualising style o Humanistic/ encouraging style o Affiliative style Passive/defensive culture o Approval style o Conventional style o Dependent style o Avoidance style

12. 14 th October 2009HIMAA National Conference Perth 2009 Culture and cultural styles in OCI Aggressive/ defensive culture  Power style  Competitive style  Perfectionistic style  Oppositional style

13. 14 th October 2009HIMAA National Conference Perth 2009 User satisfaction survey Impact of CPOE on:  work practices  patient care  satisfaction with CPOE  attitudes to CPOE

14. 14 th October 2009HIMAA National Conference Perth 2009 Results: Population and Respondents Population – 103 Response Rate – 73% Population – 103 Response Rate – 93% OCI User satisfaction survey

15. 14 th October 2009HIMAA National Conference Perth 2009 Doctors & Nurses Perception of Culture

16. 14 th October 2009HIMAA National Conference Perth 2009 Constructive Culture Styles

17. 14 th October 2009HIMAA National Conference Perth 2009 Passive-Defensive Cultural Styles

18. 14 th October 2009HIMAA National Conference Perth 2009 Aggressive-Defensive Cultural Styles

19. 14 th October 2009HIMAA National Conference Perth 2009 Attitudes to CPOE system Attitudes Doctors n=36 Nurses n=60 Using computerised test management systems: Agree % Neutral % Disagree % Agree % Neutral % Disagree % p-value Results in cookbook medicine 2811612528470.134 Depersonalises medicine 1119691012780.550 Helps in deciding which tests to order 2519567119100.000 Improves the practice of medicine 613187317100.281 Results in over ordering of tests 5814283038320.010 Alienates doctors from patients 3889629650.254 Makes my work more interesting 335017632980.024

20. 14 th October 2009HIMAA National Conference Perth 2009 Discussion Cultures are not uniform in large hospitals Constructive culture of nurses – support CPOE Aggressive-defensive culture of doctors – discourage uptake of new innovations High perfectionist style of doctors – counterproductive to implementation of new technologies

21. 14 th October 2009HIMAA National Conference Perth 2009 Implications of the results Examine sub-cultures prior to implementation Strategies for moving to a constructive culture can be employed

22. 14 th October 2009HIMAA National Conference Perth 2009 Strategies to move to constructive culture Individual level  Goal setting; job design; motivational processes Unit level  Performance appraisal; inclusive meetings Organisational level  Communication; respect for staff; employee involvement

23. 14 th October 2009HIMAA National Conference Perth 2009 Models to assist with implementing information systems Change management models Rogers EM Diffusion of Innovations, 1995 Ash’s principles Ash et al. Proc AMIA 2003 Contextual Implementation Model Callen et al. JAMIA 2008

24. 14 th October 2009HIMAA National Conference Perth 2009 Contextual Implementation Model Grounded in data Core theme of ‘contextual differences’ Diversity at 3 contextual levels –Organisational level –Clinical or departmental level –Individual level Dimensions for consideration within each level (organisational culture, unit leadership, diverse ways of working)

25. 14 th October 2009HIMAA National Conference Perth 2009 Contextual Implementation Model Organisational Context Clinical Unit Context Individual Context Use of clinical information systems Government policyEconomy IT industryProfessional groups

26. 14 th October 2009HIMAA National Conference Perth 2009 Value of models and theories To realise the potential benefits of I&CT to patients, clinicians and government we need to develop and test models of evaluation and implementation

27. 14 th October 2009HIMAA National Conference Perth 2009 Role of the health informatics specialist in implementation Health Information Managers function at the core of the change process in healthcare Play a major role in implementing, managing, and leading IT adoption to improve health care Change theories and implementation models provide a framework for understanding and supporting these large scale IT implementations

28. Thank you J.callen@usyd.edu.au