Cultural understanding yields patient safety dividends

Communication and cultural sensitivity can be lifesavers

"Hmong" may be hard to pronounce, but it's likely that nearly every staffer at St. John's Hospital in Maplewood, MN, knows that and much more about this unique population from Somalia. That's because the HealthEast System, of which St. John's is part, has made a concerted effort to understand the unique cultural concerns and communication needs of these patients in the interests of patient safety.

"Communicating with patients — that's the No. 1 risk factor for errors," asserts Pennie Viggiano, MHA, MBA, HealthEast System's director of government and special populations. "It's also a key to patient satisfaction."

St. John's has good reason to be concerned about these patients; Maplewood has the second largest Hmong (pronounced "Mung") population in the country, according to Betsy Stiles, BSN, MA, HealthEast System's director for organizational development. "It was obvious from patient and family feedback, as well as from the work force, that we needed to be even more focused than we had been and to better understand how to provide their care," she says.

"The Hmong community came here in two very fast-acting, large waves," explains Viggiano. "The first was 15 to 20 years ago; this was a new generation, who had no experience with Western medicine."

The hospital had started to do some programming around the community, says Viggiano, but it "got more expansive" two years ago with an additional influx of 15,000 Hmong within three or four months. "We worked with the state to prepare for this new influx," she notes.

The two-pronged approach, involving both communication and cultural sensitivity, has literally been a lifesaver, according to Viggiano. "We had a patient who had an ectopic pregnancy and needed emergency surgery to save her life," she recalls. "Because she was Hmong, she refused surgery, and our doctors felt completely helpless."

As her vital signs continued to decrease, the staff called for cultural liaison Mayly Lochungvu — one of several developed through the program. "She was able to bridge the two worlds and gain the patient's agreement to surgery — and it saved her life," recalls Viggiano. "We find cultural understanding to be directly related to patient outcomes." Other staff members, including a Hmong nurse, function as "culture brokers" between patients and other staff.

A broad commitment

"Our programs encompass communication, patient safety, staff recruitment and retention," says Viggiano. "We have put them into many communities — Latino, Russian, Tibetan, Somali." In addition to the aforementioned cultural liaisons, the system uses interpreters and, in the case of the Hmong, a medical director from that culture.

"This whole effort is positioned under our quality initiative and impacts all four of our major organizational strategies — employees, clinical competence, patient satisfaction, and operational efficiency," adds Stiles. "If our systems are not in line and effective for our patients, it interferes with safety and outcomes."

Cultural sensitivity and the bottom line

It also affects the bottom line, notes Viggiano. "If you can't work with the patient to find out what's going on, it becomes more costly," she explains.

Viggiano describes the program as using a "two-pronged" approach. "If you focus on a unique culture without a broader context, it leads to stereotypes," she shares. "So, we first have general training in 'Culture 101,' where we discuss the tendency to internal bias toward everyone who is the same as you, and toward everyone who is different."

The four-hour course, presented by attorney David Hunt, was attended by 500 HealthEast executives and managers. "You need to have their buy-in," explains Stiles. Hunt, she says, "has done an outstanding job helping people understand themselves as individuals and how they relate to others — that we are all different and have to be respectful of one another.

"We've also conducted e-learning training for doctors," she continues. "It takes the general cultural course and brings it down to the patient's bedside. It really talks about how to interact with the patient, to discuss why they think they are in the hospital, ask if they want a pill, discuss what you want them to take, and in general, strengthen the individualized care plans."

Each hospital unique

On top of these efforts, says Viggiano, the programs recognize the unique needs of each hospital and its particular patient base. "At St. John's, for example, in addition to this general education, there is enough uniqueness attached to the Hmong to do a secondary awareness education program around them," she says.

"We've worked with the community to help us understand what we need to know to best care for them. We've had community leaders come in and do lunch forums, we've had a nursing education day, and the community leaders made us a video about Hmong culture."

The way to build trust with such a community, she says, is to "come out of the walls of the hospital." Accordingly, the hospital CEOs and other leaders, including Stiles and Viggiano, have taken part in community events and sponsored others to learn more about the culture.

"They have 18 clans, with appointed leaders for each one," says Viggiano. "I am the health care liaison to the Hmong Council of 18; they help guide me and HealthEast to be able to best respond to Hmong patients' needs." Viggiano has met with Shamans, as well as with the clan leaders.

"Pennie has done an incredible job linking up with them; it all comes down to establishing trust so patients and families will trust what our providers are talking about," says Stiles. "This really has a direct relationship with safety."

In addition, to allay culturally based fears of Western medicine, "we have opened our labs, our surgical centers, and maternity department and conducted tours to answer questions before care is needed," says Viggiano. For example, she explains, one such belief causes a fear of having blood drawn. "They don't believe it will be replaced if we draw it," she says. "And they want to know what we do with it when we take it."

Once they do become patients, seemingly small touches can go a long way toward bridging the cultural divide. For example, an herbed chicken broth, a traditional Hmong dish for new mothers, can be ordered from the kitchen.

The overall system program — general learning and e-education, clinical quality, and recruitment and retention — are all coordinated, says Viggiano. "We all work together as a team," she says. "It's one of the top priorities in our company."

"HealthEast's whole mission is about providing the highest quality, and compassionate care, and we recognize that in order to do that we have to step back and broaden our understanding of others and link it with what care means to others, so our care can become individualized," says Stiles.

Building on lessons

HealthEast is building upon the lessons learned in this program as new refugees come to Maple-wood, says Viggiano. "There is a new group of refugees, the Karen, coming in rapidly from Burma," she notes. "We've been told by the state that they are on the way and will probably be as fast growing as the Hmong originally were. We have been able to be very proactive in formulating the lessons we've learned to help these folks learn very quickly how to react to health care and verbalize their needs. We want to be proactive with education and understanding, and remove cultural barriers before they affect care."

HealthEast also is using technology to help remain on top of cultural issues. "We are in the process of developing a database that will enable us to really be more concretely articulate about the cultural makeup of our patient population," says Stiles.