preparing an organisation for electronic clinical information systems: does culture matter? dr...

Preparing an organisation for Preparing an organisation for electronic clinical information electronic clinical information

systems: Does culture matter?systems: Does culture matter?Dr Joanne Callen

Senior Research FellowHealth Informatics Research and Evaluation Unit

The University of [email protected]

14th October 2009 HIMAA 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


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


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


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)


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


Methods

• Research setting Two clinical units:

Emergency Department and Haematology/

Oncology Ward 400 bed metropolitan

public teaching hospital


Clinical information context Computerised

physician order entry system used to order and view all laboratory and radiology tests


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


Organisational culture inventory (OCI)

• Constructive culture work cooperatively; high motivation; teamwork

• Passive/defensive cultureplease those in authority; wait for others to act first

• Aggressive/defensive culture oppose new ideas; compete; appear competent and independent


Culture and cultural styles in OCI

• Constructive culture Achievement style Self-actualising style Humanistic/

encouraging style Affiliative style

• Passive/defensive culture Approval style Conventional style Dependent style Avoidance style


Culture and cultural styles in OCI

• Aggressive/

defensive culture Power style Competitive style Perfectionistic style Oppositional style


User satisfaction survey

• Impact of CPOE on: work practices patient care satisfaction with CPOE attitudes to CPOE


Results: Population and Respondents

Population – 103Response Rate – 73%

Population – 103Response Rate – 93%

OCIOCI User satisfaction surveyUser satisfaction survey

27%

44%

29%

Doctors

Nurses

Non-respondents

35%

58%

7% Doctors

Nurses

Non-respondents


Doctors & Nurses Perception of Culture

0

10

20

30

40

50

60

70

Constructive

Passive-defensive

Aggressive-defensive

Doctors

Nurses


Constructive Culture Styles

0

10

20

30

40

50

60

70

80

Pe

rce

nti

le s

co

res

Achievem

ent

Self-ac

tuali

sing

Human

istic

Affilia

tive

Doctors

Nurses


Passive-Defensive Cultural Styles

0

10

20

30

40

50

60

Doctors

Nurses


Aggressive-Defensive Cultural Styles

0

10

20

30

40

50

60

70

80

Doctors

Nurses


Attitudes to CPOE systemAttitudes

Doctors n=36

Nurses n=60

Using computerised test management systems:

Agree%

Neutral%

Disagree%

Agree%

Neutral%

Disagree%

p-value

Results in cookbook medicine

28 11 61 25 28 47 0.134

Depersonalises medicine 11 19 69 10 12 78 0.550

Helps in deciding which tests to order

25 19 56 71 19 10 0.000

Improves the practice of medicine

61 31 8 73 17 10 0.281

Results in over ordering of tests

58 14 28 30 38 32 0.010

Alienates doctors from patients

3 8 89 6 29 65 0.254

Makes my work more interesting

33 50 17 63 29 8 0.024


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


Implications of the results

• Examine sub-cultures prior to implementation

• Strategies for moving to a constructive culture can be employed


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


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


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)


Contextual Implementation Model

Organisational Context

Clinical Unit Context

Individual Context

Use of clinical

information systems

Government policy

Economy

IT industry Professional groups


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


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

• Thank you

• [email protected]

preparing an organisation for electronic clinical information systems: does culture matter? dr...

Documents