Introduction

As patient safety is taking centre stage in the field of healthcare, various improvement programmes have been developed over the past decades. Some of them have brought us astounding improvement in the quality and safety of care, such as dramatically reducing central-line associated blood stream infections.1 The issue of patient safety is not limited to one institution or one country and therefore the hope is to share this success with the whole world by disseminating programmes with proven efficacy. As one of the pioneer examples, the success of the Johns Hopkins ‘Keystone’ project has stimulated implementation of similar programmes across the world in countries such as Spain, England, Peru and so forth.2

While the dissemination of some safety initiatives can be achieved mainly by technical changes, for example, implementing computerised prescription order entry systems, many are more bound to tap into people's behaviour, which is naturally shaped by the cultural contexts. The latter cases are more prone to cross-cultural obstacles; for example, adopting checklists has faced much resistance in countries where to-do lists are not commonly used in everyday life. For another example, ‘Speak-up’ programmes that encourage people to say something when they feel something is wrong have experienced more difficulty being accepted in a hierarchical culture where speaking up is potentially humiliating when directed to one's superior. This type of intervention tends to fail if imported ‘culturally unprocessed’ from a different country.

The business world has studied these cross-cultural issues for a long time, as the initial part of their globalisation strategy was littered with numerous failures that resulted from not taking into account the impacts of cultural diversity.3 The often quoted story of General Motors (GM) well illustrates the potential to fail in globalisation. When GM introduced a new car line ‘Nova’ in Latin America, they had not realised that the name could translate into ‘no go’ in Spanish, which is not suitable for the name of a motor vehicle. According to the anecdote, albeit considered as an urban legend, ‘Nova’ sold poorly in Spanish-speaking countries due to its name, and the sales showed an improvement only after GM changed the name to ‘Caribe’.4

Now it is well accepted that the first and most important step in any effort to penetrate a new market is to thoroughly understand the market, thereby to reduce the potential risk of failure. However, for healthcare cultural differences may not have been sufficiently considered. Unfortunately, in the healthcare field, cases of failure are rarely published in academic journals, and even when failures are reported, people rarely attribute the failures to cultural conflicts. To reduce the risk of failure in the dissemination of future safety programmes, the healthcare world needs to be mindful of potential unexpected traps presented by cultural difference.

We note that there is a striking similarity between cross-cultural dissemination and organ transplantation. The programme is equal to the organ being transplanted and both donor and recipient countries have aspirations that the programmes they transplant will function well. The success of transplantation depends not only on the quality of the organ to be transplanted, but also how well it is accepted by a recipient's body. This is why tissue compatibility between the donor and the potential recipient is meticulously checked before transplantation is performed.

The same logic applies to programme dissemination. Just as histocompatibility issues exist for organ transplantation, there are cultural-compatability issues that we should bear in mind: the risk that the disseminated programmes may not fit the recipient in terms of their unique culture. Any dissemination effort must take into account the local context and culture or risk ‘acute rejection’ of the programme. Even within a hospital, each department has its own context and every hospital has its unique culture, but we can expect these issues will be especially acute when disseminating programmes to a new country.

Illustrative examples of cultural conflict

Take a ‘speak-up’ initiative as an example to illustrate cultural diversity. It is regarded as one of the crucial domains of safety culture (eg, communication openness), which refers to barrier-less communication between healthcare professionals.5

The success of the ‘speak-up’ initiative depends on whether every member of the healthcare practice can voice their concerns freely when they observe other members not complying with evidence-based practice, without fear of reprehension. This means that managers and senior physicians must not reprimand nurses and junior physicians for voicing their concerns and everyone must feel comfortable in voicing their opinions if they observe risks to patients.

The ease of convincing managers to defer to their subordinates, and subordinates to question and challenge their superiors varies across cultures. Hofstede, a Dutch organisational sociologist, suggested the concept of ‘Power Distance’ as one of the perspectives to systematically analyse cultural differences. Power Distance is defined as the extent to which lower level members accept and expect unequal distribution of power within their organisation. The Power Distance Index (PDI) is measured in terms of the ease of expressing one's own opinion should it differ from that of a superior member.6 Hofstede scored the PDI of various nations, where a higher score reflects difficulty in expressing one's opinion (figure 1).

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Figure 1

Power Distance Index across the world (illustrated based on Hofstede's study6).

The PDI can be one of the cultural-compatibility factors to be considered for disseminating ‘speak-up’ programmes. As shown in figure 1, the PDI scores vary across nations. For instance, North American and Western European nations have relatively low PDI scores. The score for USA is 40 and that for Austria is 11, while Asian countries have much higher PDI scores; China has a score of 80, Malaysia 104. As such, a programme implemented successfully in a country with a low PDI score that encourages speaking up may not work in a country with a higher PDI score. To overcome this cultural chasm, we should understand the foundation of such cultural phenotypes and develop interventions that are effective for various levels of PDI.

Let us assume that we are disseminating a programme developed in the USA in China. Since the birth of the modern age, Western culture including that of the USA has been affected by liberalism, where equality, protection of individual rights, autonomous self, democracy, and adherence to law and regulation are emphasised. When the programme is transplanted into China, the cultural background that the programme will encounter is Confucianism, where face saving, paternalism, interdependent self and social obligation are important.7

These philosophical ideologies that have been formulated over centuries are instilled in an individual from early childhood, especially through their relationships with their family members. In Asian countries, parents and older siblings act as caretakers for young children. Thus, younger family members are expected to obey the elders' decision and judgement. On the other hand, in Western cultures, independent thinking is valued and children are encouraged to make their own decisions as soon as they can. Also, they learn how to express their opinions when it differs from others' opinions.6

Furthermore, in Asia, the workplace is treated as an extension of the family.7 A similar hierarchical structure is expected and followed, where obedience towards parents and older siblings are projected towards senior members and managers. It is almost impossible for these employees to raise their concerns even when they observe their superior making a mistake.

Gender differences also complicate this hierarchical problem: according to Goldner, a psychologist, gender exerts influence on hierarchy as profound as generations or class.8 Moreover, in Confucianism countries, where paternalism has huge influence on family relationships, the male–female hierarchy is even clearer, so much that sisters are given a lower status than their younger brothers. Considering that most nurses are women, while the community of doctors is still dominated by men, nurses in Confucianism countries are not able to express their concerns easily against doctors' decisions.

Besides the above-mentioned hierarchy and gender issues, cultural-compatibility for safety programme dissemination is vastly influenced even by seemingly unrelated factors such as religion. Hand hygiene among healthcare workers has been regarded as the most crucial factor to prevent hospital-acquired infections. Alcohol-based handrubs were recognised as more effective than soap and water,9 and have been advocated by WHO as the preferred hand hygiene protocol.10 However, when WHO tried to spread this protocol globally they faced unexpected resistance from Muslim healthcare staff, as the Quran, the holy book of Muslims which guides their religious beliefs and everyday practices, prohibits the use of alcohol. To address this issue, the WHO asked religious leaders in Mecca for help; these leaders reviewed the Quran and other literature11 and confirmed that the use of alcohol for medical purposes was permitted; this decision was then promulgated in the World Muslim League in 2002. Since then, alcohol-based handrubs have become increasingly accepted by medical institutes in Arabic countries.

This example shows that even a scientifically proven technique may experience difficulties due to cultural differences. We easily think of a successful safety programme as a tool that works in any context. However, it premises the surroundings where it was originally developed, because it was created by and intended to affect the people immersed in the very culture, just as the donor's organ was best designed for the donor's body.

Achieving success in cross-cultural dissemination

Considering the long history of cultural influence, we should never expect that we can change the cultural background of a country in a fortnight. Also, we should understand that no culture is ever wrong, or inferior to another; they are simply different. Therefore, we need to recognise the presence of the cultural differences, which can be conceptually referred to as the major cultural-compatibility complex, equivalent to the major histocompatibility complex in organ transplantation.

When preparing an organ transplantation, we first look for healthy organs and then, more importantly, verify whether the recipient's body will accept the organ by a tissue compatibility test. The same logic should be applied for safety programme dissemination. In healthcare, we have paid a great deal of attention to the first step: the search for a successful programme to import. However, more often than not, we have been missing the second, potentially more crucial step: the compatibility test. What is missing does not originate from our lack of diligence, but from the lack of an established repertoire for cultural compatibility similar to the histocompatibility complex. PDI might be one of the factors to be considered, but there are no sets of items that can predict the success of an intercultural dissemination with certainty.

However, despite these difficulties, there is hope we can rely on: while an organ once transplanted is totally wasted if the recipient fails to accept it, we can use a smaller-scale pilot test to check whether a safety programme will work in the new cultural environment. It might be more practical to look for another option if a programme yields serious issues during the pilot test. However, what is even better about a pilot test is that it will help reveal the source of conflict, so we can modify the original programme accordingly to better suit the culture to which it is to be applied. For instance, a pilot study is a great opportunity to check whether there are any translation errors and, even more importantly, whether the translated messages resonate with the new audience, as it did in the original cultural context, to achieve positive uptake. In our efforts to disseminate the programme to reduce central-line associated blood stream infections, we made available evidence-based practices and measures yet encourage local variation in the interventions used to implement those practices. While the evidence to prevent infections is universal, the methods to measure infections (although highly congruous among countries) vary slightly, and the way the evidence is implemented varies significantly, as it should. By following this approach, we can circumvent barriers originating from cultural differences.

In the meantime, ‘donors’ have to play a role in the dissemination process. Programme designers should realise that their success does not guarantee success elsewhere; therefore, they should make an effort to convey not only the programme protocols but also the information about the cultural context of the disseminated programme. If any modification to the programme is required for a better fit, the donors should take responsibility to ensure that the modification does not jeopardise the original intention of the programme through active communication with the recipients. As we saw in the alcohol-based handrubs example, when donors passionately collaborate with recipients, the likelihood of success in cross-cultural dissemination becomes higher.

As already emphasised, we are not suggesting that the cultural context with a very long history should change to fit newly imported initiatives. However, as the wise selection, modification and implementation of safety programmes accumulate, we can expect that the safety culture will gradually penetrate the areas of healthcare practices. We believe that although the conflicts between the newly introduced safety programme and the overall culture of a country still exist, patient safety will take priority when it does matter.

Patient safety is crucial in every country, regardless of its political or economic situation. The dissemination of effective safety practices can help to improve safety globally. Yet such efforts must be informed by the recipients' context and culture, the ‘major cultural-compatibility complex’. All of us know that without a meticulous compatibility test a transplantation is destined to fail, and not only the organ but the donor's goodwill is also wasted. Understanding cultural differences can be difficult and requires huge effort, but the difficulty cannot justify our negligence, because patient safety should always come first. The first step is to acknowledge that differences do exist.