Institutional culture in healthcare refers to the shared beliefs, values, attitudes, and behaviors that are present within a healthcare organization. It encompasses all aspects of the organizational structure, from its mission and vision to its policies and procedures, to the interactions and relationships among staff members.
The governance structure of a healthcare organization can play a role in improving health equity. Addressing health inequities by recognizing and decreasing institutional racism and other forms of discrimination has a significant impact on improving an organization’s institutional culture (Browne et al., 2018).
Health equity interventions can be implemented at multiple levels within an organization and at the level of clinical practice. Specific interventions can vary but are characterized by a common goal of closing the health equity gap with the aim of 1) improving the health of populations, 2) enhancing patient experience and outcomes, and 3) reducing per capita cost of care (Browne et al., 2018).
6.1 Educational Approaches
Cultural competence education is effective when it is multipronged, when people work and train together, and when it is designed with context and professional identity in mind. Training in teams helps individuals feel comfortable sharing their biases and accepting their vulnerabilities. Training in this way enhances collaboration and openness and reinforces behavioral change (Sukhera, 2020).
In one study, students who practiced responding in non-stereotypical ways to members of other groups were better able to avoid activating negative stereotypes. Other studies have found that contact between members of different groups reduces prejudices and hostilities. Equality of status, social and institutional support, pleasant contact, and intergroup cooperation produce positive results (Brusa et al., 2021).
In another study, the use of a short video modified the racial attitudes of white college students towards peers of color. Students were assigned to two experimental groups: one group viewed a short documentary depicting the life of a Caucasian and a Black subject, followed by hidden cameras over the course of a day, the other group did not view the video. Researchers found that the experimental group showed reduced prejudicial attitudes and reduced fear of minorities compared to the control group (Brusa et al., 2021).
A widely used tool for understanding and improving cultural sensitivity is Bennett’s Developmental Model of Intercultural Sensitivity. Milton Bennett, a professor at Portland State University in Oregon, developed the tool as a framework to explain how people experience cultural differences. It provides a roadmap of how we move from an ethnocentric to an ethnorelative perspective and highlights stages of development with the goal of intercultural acceptance, adaptability, and integration. It nicely sums up the principles discussed in this course.
Learn more about this tool here: https://www.idrinstitute.org/dmis/
6.2 Promoting Collaboration on Healthcare Decisions
The World Health Organization describes collaborative practice as occurring when healthcare workers from diverse professional backgrounds work with patients and their families to deliver high quality care. The involvement of patients as central to healthcare is recognized as essential and differs fundamentally to traditional clinician-centered healthcare (Davidson et al., 2022).
Collaborative decision-making occurs when patients work together with their healthcare providers to make decisions about screening, treatments, and managing chronic conditions. Shared decision-making allows people to take an active role in their healthcare decisions. With shared decision-making, the person’s individual preferences, beliefs, and values are considered when making health decisions (Jull et al., 2021).
Importantly, shared decision-making helps people understand the risks and benefits of different options through discussion and information sharing. In fact, shared decision-making has been called “the pinnacle” of person-centered care. A key feature of shared decision-making is the exploration of patient values and priorities, which can be facilitated by using evidence-based decision support tools and approaches (Jull et al., 2021).
“Decision-coaching” and “decision aids” help patients take an active role in their healthcare decisions. Decision aids include booklets, videos, and online tools that help people clarify what matters to them. These tools help people feel more knowledgeable, better informed, and encourage them to take an active role in decision-making (Jull et al., 2021).
6.3 Case Review
In the example that follows, the failure of an organization to provide language assistance services (or the doctor’s failure to use available services) lead to a frustrating experience for the doctor, the hospital, and the patient.
Example Case: Mr. Louis and His Granddaughter
Mr. Louis just celebrated his 70th birthday with his family and neighbors with lots of good food, music, and dancing. Mr. Louis kept everyone up late, telling stories about his childhood in Haiti. Mr. Louis was grateful to have so many loved ones close by, but he still misses Haiti after moving so many years ago.
Soon after his birthday, Mr. Louis visited his physician for a checkup. His physician sent him for additional testing, which showed the presence of prostate cancer. Let’s see what happens during Mr. Louis' appointment with the oncologist, Dr. Emily Parker.
The Initial Appointment
Mr. Louis, who knows some English brought his granddaughter, Esther, to his oncology appointment at the hospital to help him speak with the oncologist. He was worried that he would not understand everything that the doctor might say. Plus, Mr. Louis was nervous, he wanted his granddaughter there for support.
Once the appointment began, Dr. Parker and Esther did all the talking. Mr. Louis did not get a chance to speak, and he did not understand much of what Dr. Parker and Esther were saying. After a few minutes, Esther seemed to be arguing with Dr. Parker. This embarrassed Mr. Louis, and he stayed quiet.
After the First Appointment
After the appointment, Esther explained to her grandfather in French that, to treat his cancer, he would undergo a procedure the next week that would implant radioactive seeds. Esther told Mr. Louis that the procedure was simple, painless, and without side effects. She did not mention what else the doctor said or what she seemed they seemed to be arguing about during the visit.
Back at home, Mr. Louis began to worry about the procedure. He researched the procedure online and talked with his friends. He learned that the procedure did have side effects, including the possibility of incontinence. Remembering how Esther had argued with the doctor, Mr. Louis wondered if she had told him the truth about her conversation with Dr. Parker.
The Surgical Appointment
The next week, Mr. Louis and Esther arrived at the admissions office at the hospital. “No surgery,” said Mr. Louis firmly. The admissions clerk looked up in surprise, and Esther quickly started talking to her in English. She explained that Mr. Louis did not really understand the issue and that he really did want the surgery.
Esther asked to sign the papers for her grandfather, but the admissions clerk explained that without legal standing, Esther was not eligible to do so. Mr. Louis continued to quietly say, “No surgery.” The admissions clerk had no idea what to do. The surgical staff called to say that they were waiting for Mr. Louis. Esther glared at her grandfather.
The clerk spent almost half an hour trying to find a hospital staff member who spoke French, but no one was available. The surgery staff called again, saying that if Mr. Louis did not arrive shortly, they would have to reschedule his procedure.
Exasperated, Esther insisted that Mr. Louis undergo the procedure. She said, “The hospital has people ready to do this. All those people’s time will just be wasted. Come on, just sign the paper and we can get you upstairs.” Mr. Louis said again, “No surgery.” Esther had no choice but to take him home.
Mr. Louis’s Response
“I depended on my granddaughter to help me with my oncology appointment. But she did not tell me the truth about the surgery and my options to treat my illness. I am really angry that I came very close to having a surgery I did not want! It was so frustrating to not be able to communicate directly with my doctor. All I wanted was someone who could listen to me and explain my options.”
Mr. Louis’s Doctor Responds
“These days, I see a lot of patients who don’t speak English very well or at all. I’m used to communicating with a family member or friend instead of the patient. In fact, I ask patients to bring someone who can interpret for them. It’s so much easier that way!”
“But when I heard about Mr. Louis’ situation from our admissions clerk, I was shocked! I did not recommend the procedure that Esther scheduled for her grandfather. I actually suggested “watchful waiting” as Mr. Louis’ treatment option.” But, during the consultation, his granddaughter insisted that Mr. Louis undergo the procedure. “Now that I think about it, I didn’t speak much with Mr. Louis since Esther seemed to be in charge. I thought I was doing the right thing by speaking with the family member that Mr. Louis brought with him. Now, knowing that Mr. Louis did not want surgery scares me. I wish I had been able to speak directly with Mr. Louis without his granddaughter interfering.”
Conclusion
Offering language assistance services, including a competent medical interpreter, helps patients with limited English proficiency understand and make informed decisions about their medical care. Unfortunately, Mr. Louis almost had a surgery that he did not want, and the surgery could have caused side effects about which he had not been informed. Operating on a patient who did not want surgery or who was not aware of potential adverse effects could have serious liability implications for the doctor and the hospital.
Furthermore, the hospital had a surgery team and room sitting idle because a patient was scheduled for a procedure that he did not want. In this case, the cost of providing a trained interpreter would have been significantly less than the costs that the hospital incurred from this.
Think About It
- How would you feel if this happened to you or a family member?
- Could this happen at your organization?
- Does your workplace offer communication assistance?
Source: HHS, 2022.