The Importance of Culture in Health Care Settings [and its relationship to safety and quality] Australian Institute of Health Innovation Professor Jeffrey Braithwaite, PhD Centre for Clinical Governance Research Australian Institute of Health Innovation March 24 2014 1:30pm 2:30pm Boulevard Auditorium Brisbane Convention & Exhibition Centre
Australian Institute of Health Innovation s mission Our mission is to enhance local, institutional and international health system decision-making through evidence; and use systems sciences and translational approaches to provide innovative, evidence-based solutions to specified health care delivery problems. http://www.med.unsw.edu.au/medweb.nsf/page/ihi 2
Background - the Centre The Centre for Clinical Governance Research undertakes strategic research, evaluations and research-based projects of national and international standing with a core interest to investigate health sector issues of policy, culture, systems, governance and leadership. http://www.med.unsw.edu.au/medweb.nsf/page/clingov_about
Research team Professor Jeffrey Braithwaite Foundation Professor and Director, Australian Institute of Health Innovation, UNSW Professor Enrico Coiera Professor and Director, Centre for Health Informatics Professor Ken Hillman Professor and Director, Simpson Centre for Health Service Research Professor Johanna Westbrook Professor and Director, Centre for Health Systems and Safety Research
Culture let s begin at the start Anthropology: 1952 Famously, Kroeber and Kluckhohn compiled 162 definitions of culture that were current in the anthropological literature at the time High culture = cucumber sandwiches, Royal Doulton and Queen Elizabeth
Sourdough bread Made by Cathy and Franck from Fournil97 Bakery The starter/mother dough - culture Fed quality flour and water Every bakery s sourdough is different, due to the culture, starter and humidity. The same starter has been used at a San Francisco bakery since 1849.
Sourdough culture Culture of the sourdough is unique to the locality Takes two days to go sour Sour = lactobacilli Activating wild yeasts And micro-organisms Careful: moulds or yeasts can produce toxins You can t stop the mother culture
Sourdough tips [Starter culture] Notes for potential bakers: 1. It takes time to care for the starter culture 2. Feed it weekly with flour and water it needs nourishing 3. Watch out for excessive lactic acid, toxins and micro-organisms that can spoil the experience
Another type of culture Workplace culture: sets of beliefs, ideas, practices and behaviours The way we do things around here Our: worldview, assumptions, taken-forgranted, outlook, norms, values The collective things we agree on, taking these things for granted
Where do these cultures emerge? What kinds of healthcare settings? Hospitals - private (and public) Community health settings Aged care facilities Medicare Locals General practices Others?
Incidentally, I thought I would review the literature Exciting! I found a paper in the medical literature on this topic: A Study On The Cultural Differences Between Public And Private Hospitals In Bucharest
Culture models The iceberg model of culture Above the waterline lie the observable workplace behaviours, practices and discourse: this is the way we do things round here. Below the waterline lie the underlying beliefs, attitudes, values, philosophies and taken-for-granted aspects of workplace life: why we do the things we do round here. [Braithwaite, 2011]
Culture models Schein s model Visible artefacts [eg, structures, dress, ceremonies] Espoused beliefs and values [eg, assertions, strategies, goals] Unconscious assumptions [eg, taken for granted expectations, thoughts, feelings]
Culture models Quinn and Rohrbaugh s competing values model
Culture book: selected contents Management cultures Performance and culture Professional conflicts Bullying Team climate Clinical information systems Networks, culture and reform
Culture what to do about it You run a part of a private health system, work as a manager, or director of a division, or have some quality, or patient safety, or other role? You want to change [influence, shape, intervene, manipulate, alter] the culture? Do this.
Culture - observations Use a model [which one appeals or fits your purpose? Iceberg? Schein s? Quinn s?] Enrol colleagues/supporters Create a critical mass Develop a plan and vision Take some baseline measures Go to it try to change things
Stop! Relating this to safety and effectiveness That was if you want to change the culture And of course you do, but the title of this talk is The Importance of Culture in Health Care Settings [and its relationship to safety and quality] What have we done already to do this?
We ve done all this Safety improvement programs [training] Root cause analyses Incident monitoring Met/RRTs Accreditation Credentialling Standards Policy Guidelines Procedures, checklists Restructuring Inquiries when things go wrong Try harder Hope [Insert your favoured strategy here]
Why have we done all this?
The quality and safety problem The incidence of: Experiencing an adverse event in an intensive care unit [1] 1 : 2 Being injured if you fall in hospital [2] 1 : 2 An adverse event in ICU being serious enough to cause death or 1 : 10 disability [3] Experiencing an adverse event or near miss in hospital [4] 1 : 10 Experiencing a complication from a medication or drug [5] 1 : 20 Developing a hospital acquired infection [6] 1 : 30 [1] Andrews et al, 1997; [2] Schwendimann et al, 2006; [3] Andrews et al, 1997; [4] CCGR data, average across studies in Australia, Canada, Denmark, New Zealand, UK and USA; [5] Andrews et al, 1997; [6] Pittet, 2005;
The quality and safety problem The incidence of: Being harmed while in hospital [7] 1 : 300 Dying from a medication error in hospital (as an inpatient) [8] 1 : 854 Having a retained foreign body after surgery (intra-abdominal) [9] 1 : 1,000 Being subjected to wrong site surgery [10] 1 : 112,999 Dying as a result of anaesthesia [11] 1 : 250,000 Contracting HIV as a result of a screened blood transfusion [12] 1 : 2,600,000 [7] Multiple sources of data, averaged by CCGR across studies in Australia, Canada, Denmark, New Zealand, UK and USA; [8] Kohn et al, 1999; [9] Gawande et al, 2003; [10] Kwann et al, 2006; [11] JCAHO,1998; [12] Lackritz et al, 1995.
The other side of the quality and safety problem The levels of appropriate care delivered in Australia? Care in line with evidence or guidelines? Answer: 57%
Relating this to safety and effectiveness There is evidence that higher levels of group culture are associated with higher levels of safety climate [Hartmann et al 2009] Building a culture of patient safety requires
Relating this to safety and effectiveness Creating partnerships with patients, service-users and carers Having good relationships between clinicians i.e., teamwork Ensuring effective communication between clinicians and patients
Relating this to safety and effectiveness Prioritising education, training and research on patient safety Providing decision-makers [clinicians and managers] with useful information Reporting, analysing and learning from adverse events
So far so good But what underpins culture? Answer: people and networks
Networks
Burt & Ronchi 2007: The small world of organisations and markets
Six degrees of separation Joe Sutliff Science magazine
Yet healthcare looks like this 32
Thus It s utterly essential we have multi-disciplinary teamwork To capitalise on the six degrees of separation model and better leverage our connections
Question Do we have connected, multidisciplinary teamwork? Let s check: Who s ever worked in a well connected, multi-disciplinary team?
Question Not everyone then Let s check again: Who works in a well connected, multi-disciplinary team now?
But we need teams don t we? Nurse, get on the internet, go to Surgery.com, scroll down and click on the Are you totally lost? icon. kineticwife.blogspot.com
But Have I mentioned how tribal health care is?
We do research looking at social networks Nurse from SHSEH Two friends at RNSPH Family More friends Connector Nurses from SPH School friends
Social network analysis in an ED Admin 12 Admin 1 Sr nurse 22 Admin 11 Sr dr 3 Admin 8 Admin 9 Allied health 3 Jr RN 9 Sr nurse 13 Admin 5 Jr dr 2 Sr RN 13 Sr RN 14 Sr RN 6 Sr nurse 18 Admin 4 Sr nurse 1 Sr RN 1 Sr nurse 9 Jr dr 10 Jr dr 21 Sr nurse 11 Admin 3 Jr dr 7 Sr nurse 21 Sr dr 7 Jr dr 15 Sr nurse 6 Admin 2 Jr dr 20 Sr dr 5 Jr RN 4 Jr dr 8 Sr nurse 17 Ward asst 1 Sr nurse 2 Admin 10 Admin 7 Jr dr 5 Sr dr 4 Sr dr 1 EN 4 Sr nurse 4 Sr RN 5 Admin 6 Jr dr 17 Sr nurse 8 Jr dr 12 Sr RN 4 Sr nurse 10 Ward asst 2 Jr dr 9 Jr dr 23 Sr nurse 5 Jr dr 1 Sr dr 2 Sr RN 7 Sr nurse 14 Sr nurse 12 Allied health 4 Jr dr 4 Sr nurse 3 Jr RN 10 Sr RN 8 Sr dr 6 Jr RN 8 Sr nurse 7 Jr dr 13 Jr RN 11 Jr RN 3 Sr RN 2 Jr dr 16 Sr nurse 15 Sr RN 10 Jr dr 29 Jr dr 6 Jr dr 11 Jr RN 1 Sr nurse 16 Allied health 2 Jr RN 6 Sr RN 3 Jr dr 22 EN 5 EN 2 Jr dr 18 Jr dr 24 Jr RN 7 Jr RN 2 Jr dr 25 EN 1 Sr RN 9 EN 3 Allied health 1 Jr RN 5 EN 6 Sr RN 11 Sr nurse 20 Jr dr 14 Jr dr 19 Jr RN 12 Sr RN 12 Jr dr 3 Sr nurse 19 Jr dr 27 Jr dr 30 Jr dr 26 Jr dr 28 Problem solving networks in an ED Nurses Doctors Allied health Admin and support [Creswick, Westbrook and Braithwaite, 2009] 39
Social network analysis in an ED Admin 1 Admin 12 Ward asst 1 Sr RN 14 Admin 8 Allied health 3 Sr RN 13 Admin 7 Sr nurse 22 Jr dr 26 Admin 3 Jr dr 30 Sr nurse 1 Admin 4 Jr dr 28 Allied health 4 Admin 9 Allied health 2 Sr dr 3 Sr nurse 13 Admin 11 Sr nurse 11 Admin 5 Jr dr 27 Sr nurse 9 Jr dr 2 Sr RN 8 Admin 10 EN 6 Sr nurse 21 Sr dr 4 Jr dr 25 Sr nurse 2 Sr dr 6 Sr nurse 12 Sr nurse 17 Jr dr 9 Jr dr 20 Jr dr 6 Sr dr 2 Jr RN 4 Admin 2 Ward asst 2 Sr nurse 3 Sr nurse 4 Admin 6 Jr dr 10 Sr dr 1 Sr nurse 10 Sr RN 4 Jr dr 29 Jr dr 8 Sr nurse 6 Sr dr 7 EN 1 Sr RN 1 Sr RN 7 Sr RN 6 Jr dr 3 Sr RN 11 Jr RN 11 Allied health 1 Sr RN 9 EN 2 Sr nurse 5 Jr dr 19 Jr dr 24 Jr RN 10 Sr nurse 8 Sr nurse 20 Sr dr 5 Jr RN 2 Jr dr 11 Sr nurse 14 Jr dr 12 Jr RN 3 Sr RN 2 Jr RN 6 Jr dr 17 Jr dr 21 Jr RN 8 EN 5 Sr nurse 7 Jr dr 22 Jr dr 1 Sr RN 10 Jr dr 23 Sr RN 5 Sr nurse 19 Jr dr 16 Jr dr 15 Jr RN 1 EN 4 Jr dr 18 Sr nurse 15 Jr dr 7 Jr RN 9 Sr nurse 16 Jr dr 4 Jr dr 13 Jr RN 5 Jr dr 5 Jr RN 7 Jr dr 14 Sr nurse 18 EN 3 Sr RN 3 Jr RN 12 Sr RN 12 Medication adviceseeking networks in an ED Nurses Doctors Allied health Admin and support [Creswick, Westbrook and Braithwaite, 2009] 40
Social network analysis in an ED Jr dr 20 Jr dr 27 Jr dr 22 Jr dr 25 Jr dr 1 Jr dr 26 Jr dr 10 Jr dr 5 Jr dr 16 Jr dr 18 Jr dr 28 Sr dr 3 Jr dr 15 Jr dr 3 Jr dr 7 Jr dr 17 Jr dr 14 Jr dr 13 Jr dr 8 Jr dr 19 Jr dr 6 Jr dr 4 Allied health 2 Admin 1 Allied health 1 Sr RN 13 Jr RN 2 Jr dr 2 Admin 3 Sr dr 1 Sr dr 4 Sr RN 14 Sr dr 7 Sr nurse 1 Sr dr 2 Sr dr 5 Sr dr 6 Sr nurse 11 Sr nurse 22 Sr nurse 4 Allied health 3 Sr nurse 5 Admin 5 Admin 2 Admin 4 Admin 9 EN 5 Sr nurse 12 Sr RN 11 Ward asst 2 Sr RN 5 Admin 12 Admin 11 Sr nurse 3 Admin 10 Admin 8 Allied health 4 Sr nurse 10 Sr RN 4 Sr nurse 6 EN 6 Jr RN 1 Sr nurse 15 Jr dr 9 Admin 6 Sr nurse 9 Sr nurse 20 Jr dr 11 EN 4 Jr RN 3 Sr nurse 2 Jr dr 24 Jr RN 10 Jr RN 9 Sr RN 7 Jr RN 8 Sr nurse 13 Sr nurse 8 Sr nurse 14 Sr nurse 17 EN 1 Sr RN 2 Jr dr 23 Jr RN 7 Jr RN 6 Jr RN 11 Sr nurse 18 Sr nurse 21 Sr RN 3 Sr nurse 16 Sr RN 8 Sr RN 12 Sr RN 6 EN 2 Jr dr 21 Sr nurse 7 Sr nurse 19 Jr RN 4 Sr RN 1 Sr RN 10 EN 3 Jr dr 12 Sr RN 9 Jr RN 12 Jr RN 5 Admin 7 Ward asst 1 Socialising networks in an ED Nurses Doctors Allied health Admin and support Jr dr 29 Jr dr 30 [Creswick, Westbrook and Braithwaite, 2009] 41
And so Health care is very tribal?
Insights into clinicians tribalism 5 4 3 2 Doctors tend to respond here or here, decisively AHPs tend to respond here [Source: Braithwaite and Westbrook; several studies] Strongly agree Agree Neutral Disagree Strongly disagree 1 0 Nurses tend to respond in a block here or here or here
Just how networked and tribal are we, here, then? Let s find out
Policymakers Leaders, Managers Regulators Media Insurers Others Allied health professionals Doctors Nurses Patients
Discussion, questions?
Thank you
Contact details Jeffrey Braithwaite, PhD Foundation Director Australian Institute of Health Innovation Director Centre for Clinical Governance Research Professor, Faculty of Medicine University of New South Wales SYDNEY NSW 2052 AUSTRALIA Email: j.braithwaite@unsw.edu.au Wiki: http://en.wikipedia.org/wiki/jeffrey_braithwaite Web: http://clingov.med.unsw.edu.au