1. The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b This material (comp2_unit1b) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

2. Introduction to the Culture of Healthcare Learning Objectives 2 Distinguish between disease and illness (Lecture a) Discuss the relationship between health and the healthcare system (Lecture a, b) Define 'culture' in the classic sense, as well as in the modern sense of the term, and what it means for culture to be partial, plural, and relative (Lecture a, b) Explain the concept of 'cultural competence’ (Lecture a) Explain the concepts and distinguish between 'culture', 'cultural safety', and 'safety culture', as applied to organizations (Lecture a) Be aware of the multiple cultures that interact in healthcare delivery (Lecture a, b) Define 'acculturation' and how it relates to working in healthcare settings (Lecture a) Be able to give examples of health informatics applications of the study of culture (Lecture a, b) Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

3. The Culture of Healthcare 3 This lecture: Why is healthcare culture important, and how can we learn more about it? Previous lecture: What is meant by the word “culture” when we talk about healthcare and healthcare professionals? Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

4. Why Learn About Healthcare Culture? Survey of Informatics Alumni in Practice What is the most important thing for non-health professionals to understand about clinical practice? “How clinical practices operate -- the bureaucratic, political, and hierarchical structures of the organization and the way people are expected to relate to each other” “If I am designing or implementing a system… it's imperative that I spend time in every setting that I can, to get a feel for what each clinician does in the course of his or her day” “Only by understanding what the clinician experience is, can you meet technology needs” “They need to understand the user - how they work, how they think, what their challenges/frustrations are and how you can help them” “Having an understanding of the basic roles, responsibilities, approaches and workflows of members of the healthcare team” 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

5. Why Learn About Healthcare Culture? Survey of Informatics Alumni in Practice Any other comments or suggestions about teaching non health professionals to work with H. I T. in clinical settings? “Expose students to a variety of settings.... push students to probe more deeply when getting feedback from clinicians” “Team work - not just between you and clinicians, but the whole healthcare team including admin, vendors, patients, researchers, etc. You just might be the piece that pulls/holds everyone together” “Always shadow the intended user many times before attempting an HIT intervention” “Give them as much exposure as possible to a variety of clinicians and clinical settings to remove some of the mystery” “Suggest they volunteer. Not so much on the clinical level, but staff, admin, and patient/visitor. In my field most jobs want experience in certain applications. It was helpful to at least see how these work” 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

6. Defining Terms: Culture Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. (US DHHS) Healthcare culture: language, thought processes, styles of communication, customs, beliefs, institutions that characterize the profession of nurses (or doctors, allied health workers, clinic managers etc.) Learned in part through participation in customs, rituals, rules of conduct, often not formal or explicit 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

7. Updating the Concept of Culture Culture - concept developed by expanding Western civilizations for physically isolated groups of people Presumes the observer’s culture is ‘normal’ Taken to mean static, “closed, coherent system of meaning and action in which an individual only and always participates” The concept is outdated global communication, transportation, migration not closed, not single, not constant, not static 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

8. Culture is Relative Any description of a given culture is grounded in the language and culture of the observer Agar calls this Langua-Culture (Agar, 1991) So the description of a culture depends on the people observed *and* on the observer We don’t produce a description of a culture, but a description of the difference between two cultures Like velocity – the velocity of a body in motion is always relative to a reference point, not absolute Any description of a culture is always relative to some reference culture (one’s own) 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

9. Culture is Plural and Partial For any particular kind of person, group, or situation more than one culture will always be in play. No single cultural tradition or reference defines or explains behaviors or interaction The patient is a middle aged nurse from Texas gender? religion? education? other? We have to think of the plural, cultures, for a full understanding of any observation 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

10. Ethnography Ethnography: anthropologist’s description of what life is like in a “local world,” a specific setting in a society— usually different from that of the anthropologist Ethnographer visits a foreign place, learns the language, and, systematically, describes social patterns in a particular village, neighborhood, or network Great importance placed on understanding the native’s point of view Ethnography emphasizes engagement with people and with the practices they undertake in their local worlds. 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

11. Rich Points Behaviors that highlight cultural differences Consider names used in different departments: doctors & others:“patient” counselors, others“client” business office“customer” medical library“patron” IT department“user” Imply assumptions about status, goals, relationship May have negative connotations from a different cultural reference point: “chief complaint” 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

12. Chasing Rich Points Exposed to other cultures, we notice “rich points” The job is to chase “rich points” that help translate meaning from one culture to another Culture is not a property of them or us, it is a translation between the two. And it is never a complete translation, always partial. This applies to traditional cultural translation, e.g. traditional medicine to Western medicine It also applies to professional cultural translation: health professional to HIT professional 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

13. Challenges to Cultural Competence for Medical Students Resistance –“I didn’t come to medical school to learn this” –“we have more important things to worry about” Ethnocentrism or denial of own culture/bias Stereotyping and oversimplifying –Culture not monolithic but is relative, plural, partial Othering –Group defined as different from ‘norm’ group –labeled, marginalized, excluded 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

14. Challenges to Cultural Competence for Informatics Students? Resistance –“I didn’t come to informatics school to learn this” –“we have more important things to worry about” Ethnocentrism or denial of own culture/bias Stereotyping and oversimplifying –Culture not monolithic but is relative, plural, partial Othering –Group defined as different from ‘norm’ group –labeled, marginalized, excluded (‘users’) 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

15. Where to Look People in Healthcare –Health Professionals –Everyone else Places of Healthcare –Clinics, hospitals, etc. Processes and practices –What do they do? Why? Values –written and unwritten Interaction with technology symbols – (white coats) language – ‘medical talk’ values - e.g. nursing to put “patient at ease” norms – often in heuristics: “treat the patient, not the lab” folklore – stories convey implicit values ideology – explicit values mass media – public perception 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

16. Cultural Assumptions May Hinder Practical Understanding modern anthropology rejects the idea of isolated society with fixed set of beliefs leads to stereotyping – may get in the way of solving the problem translate this to HIT and health professional interaction- reject the idea of an isolated society with a fixed set of beliefs focus on issues, not cultural stereotypes (professional culture or otherwise) 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

17. Field Studies to Support HIT Design and Evaluation - Examples Workstation design based on ethnography of work practices Fafchamps 1991 Forsythe 1992 Computer supported cooperative work, collaborative sense making and information use in critical care, emergency care Forsythe 1999 Ho 2007 Paul 2010 Bar code medication technology impact, side effectsPatterson 2002 Informal information sharing in critical careVuckovic 2004 Computerized order entry impact on doctor nurse cooperation, cognitive analysis Beuscart-Zephir 2005, Physician patient interaction with exam room computers, video ethnography Ventres 2006 Language differences among physiciansBruzzi 2006 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b 9.3 Table (Gorman, 2010) Used with Permission.

18. An Overview of the Culture of Healthcare Summary – Lecture b Effective HIT requires understanding of Healthcare culture: clinical settings, processes, and people Modern concept of cultures as always plural, always partial, always relational depending on both observer and observed Rich points are behaviors that highlight cultural differences – differences in language, for example Cultural competence important for health informatics - avoiding stereotypes, ethnocentrism, ‘othering’ Rich insights can inform design and evaluation of HIT in clinical settings 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

19. An Overview of the Culture of Healthcare Summary Culture: classic sense and modern sense Culture: partial, plural and relative Cultural competence, cultural safety, just culture Importance of understanding multiple cultures in context Rich points, acculturation Use of health informatics in the study of culture 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

20. An Overview of the Culture of Healthcare References – Lecture b 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b References Agar, M. (1991). The biculture in bilingual. Language in Society, 20, pp 167-182 doi:10.1017/S0047404500016250 Beuscart-Zephir, M. C., Pelavo, S., Anceaux, F., Meaux, J., Degroisse, M., & Degoulet, P. (2005, August). Impact of CPOE on doctor–nurse cooperation for the medication ordering and administration process. International Journal of Medical Informatics, 74(7-8), 629-641. Retrieved from http://www.sciencedirect.com/science/article/pii/S1386505605000158 Boutin-Foster C, Foster JC, Konopasek L. Physician, know thyself: The professional culture of medicine as a framework for teaching cultural competence. Acad Med 2008;83(1):106–11. Bruzzi, J. F. (2006, February). Perspective: The Words Count — Radiology and Medical Linguistics. New England Journal of Medicine, 354, 665-667. Fafchamps D, Young CY, Tang PC. Modelling work practices: input to the design of a physician's workstation. Proc Annu Symp Comput Appl Med Care. 1991:788–792. Forsyth, D. R. (1999).Group dynamics (3rd ed.). Belmont, CA: Wadsworth. Forsythe DE, Buchanan BG, Osheroff JA, Miller RA. Expanding the concept of medical information: an observational study of physicians' information needs. Comput Biomed Res.1992 Apr;25(2):181–200. Ho, D., Xiao, Y., Vaidya, V., & Hu, P. (2007). Communication and Sense-Making in Intensive Care: An Observation Study of Multi-Disciplinary Rounds to Design Computerized Supporting Tools. AMIA Annual Symposium Proceedings Archive, 329–333. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2655920/ Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. Public Library of Science Medicine, 3, 1673–1676.

21. An Overview of the Culture of Healthcare References – Lecture b (continued) Charts, Tables, Figures 9.3Table: Gorman, P. (n.d.) Field Studies to Support HIT Design and Evaluation – Examples. Retrieved from author, Used with Permission. References (continued) Patterson, E. S., Cook, R. I., & Render, M. L. (2002). Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration. J Am Med Inform Assoc, 9, 540-553. Paul, S.A., Reddy, M.C.: Understanding together: sensemaking in collaborative information seeking. In: Proceedings of the 2010 ACM Conference on Computer Supported Cooperative Work, pp. 321–330. ACM, Savannah (2010) Saikh, B. T. (n.d.). Supercourse. Retrieved November 20, 2011, from http://pitt.edu website: http://pitt.edu/~super1/lecture/lec9321/001.htm http://pitt.edu/~super1/lecture/lec9321/001.htm Ventres, W., Kooienga, S., Vuckovic, N., Marlin, R., Nygren, P., & Stewart, V. (2006, March). Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis. Annals of Family Medicine, 4(2), 124-131. Retrieved from http://www.annfammed.org/content/4/2/124.short Vuckovic, N. H., Lavelle, M., & Gorman, P. (2004, September). Eavesdropping as Normative Behavior in a Cardiac Intensive Care Unit. National Association for Healthcare Quality, W5-1 - W5-6. Retrieved from www.nahq.org/journal 21 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b