Hoag care catered to Asian Americans

IRVINE — The poor nurse just thought she was bringing a refreshing dessert — a popsicle — to a new mother. She didn’t expect the grandma, shocked, to stop her and intercept the treat.

While refreshing to many, the cold was taboo for Shu-Fen Chen.

After emigrating from Taiwan, Chen gave birth to her first child in a Los Angeles hospital. Her cultural beliefs say a new mother shouldn’t touch anything cold for a month after birth, or she will suffer headaches later in life, she says.

Eventually, Chen moved to Irvine, home to one of the largest Chinese American populations in the nation and once home to Irvine Regional Hospital, where she had her second child. There, the nurse knew better.

“So many traditions people cannot believe,” said Chen, the executive director of the South Coast Chinese Cultural Assn. in Irvine. “But some nurses just understand our culture.”

As Hoag Hospital opens its Irvine campus on Wednesday, replacing Irvine Regional, administrators are hoping they have done enough to understand Irvine residents’ cultural beliefs, traditions and language.

Since the 1950s, Hoag has served mostly white and increasingly Latino patients at its Newport Beach location: Newport is 90% white, the Census Bureau estimates. Now, the hospital is stepping into a community with nearly 40% Asians and a large Iranian population.

Hoag executives have planned a number of methods to please their future customers. The gestures, while subtle, represent new thinking for the conservative institution.

They range from creating feng-shui patient rooms to serving steamed rice for breakfast, and less-tangible gestures like respectfully presenting documents with two hands and speaking to patients with more formality.

“Health care’s not just about your clinical ability. You’ve got to do it in a way that connects with patients,” said Robert Braithwaite, Hoag Irvine’s chief administrator. “That means understanding their cultural heritage and how they want you to communicate.”

Experts say that families and patients certainly vary in their individual values and beliefs, but it can be very useful, if not imperative, to be aware of collective tradition.

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OUTREACH

The acculturation of Hoag evolved during dozens of meetings Braithwaite held with community groups. He and physicians met with the Irvine Evergreen Chinese Senior Assn.; NEDA, an Iranian Group; and non-ethnic groups such as the AARP. They listened to comments about hospital plans.

Don’t have a fourth floor, some residents said, because the No. 4 is associated with death for many Chinese and Koreans, the two largest Asian ethnic groups in Irvine.

So the hospital removed the fourth-floor elevator buttons and signs during the nearly $90 million renovation of the old Irvine Regional building.

“It’s so easy to make those gestures and to be responsive,” said Sanford Smith, the hospital’s senior vice president of facilities.

He previously worked for Toyota and understood cultural sensitivity, he said.

Hoag also retained a cultural consultant and talked with executives from the Irvine Co. and the Great Park about their experiences serving people with an Asian or Middle Eastern heritage.

“It’s a pretty deep learning experience,” Braithwaite said while the hospital was still under construction.

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TRADITIONAL BELIEFS

Hoag designers learned that mountains are associated with wisdom, for instance, and that colors are key in traditional Chinese ying-and-yang balance. They devised a “mountains-to-sea” theme for the hospital, representing a trail by that name that connects Irvine to Newport Beach.

“In the Asian culture, nature is a core element of the healing process, much more so than in Western medicine,” Braithwaite said.

A patient is more likely to hold onto such cultural traditions if he or she has lived in a tightly knit ethnic enclave, experts say.

“For those who have been here for multiple generations, you’d want to know what traditional beliefs stayed intact and what their recent experience has been with medical care,” said Vivian Jackson, a senior associate at the National Center for Cultural Competence in Washington, D.C.

Hoag executives are betting that enough of them will appreciate feng shui patient rooms — 76% of the foreign-born Irvine residents are from Asia. An ancient Chinese philosophy that concerns the art and science of placement, feng shui influenced Hoag designers, the administrators said.

Major reconfiguration was limited, though, by the existing hospital’s medical gas lines.

“We moved seating around and bed position to overall improve the flow of the room,” Braithwaite said.

Even less-tangible cultural awareness could have an effect on the patient’s care – more so than landscaping and building design, experts say.

Hospital staff will need to mind how families respect their elders — some Chinese American children might not inform parents of their illness to “protect” them, one research study found. Also, they could be reluctant to discuss advance directives.

Jackson said the hospital should have an ethics committee familiar with such issues and policies ready when they arise.

She said a physician might even offend a family, for example, by asking the actual patient, a mother, for direction on care, when the father or the eldest son would be the decision-maker.

“Sometimes it’s those kinds of things that can be more problematic than the substance of the actual medical care,” she said.

Hoag will use the same ethics committee it does at its Newport location, and that group is familiar with cultural issues, said spokeswoman Debra Legan.

She pointed out that many Irvine residents already come to Hoag for treatment.

The food will change, though, with an added “touch of Asian” that includes vegetarian tofu stir-fry, miso soup and steamed rice with every meal.

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COMMUNICATION

Clearly, the most important cultural factor is language.

Hoag hired interpreters who speak Mandarin and Persian. It also contracted with AT&T to provide translation over phones installed throughout the hospital. Registration materials will be in Mandarin, Korean, Persian and English.

Wayfinding signs, though, will be in English. The instructions provided by the hospital pharmacy are printed in Spanish and English.

Language is the biggest consideration for many Chinese-Americans, said Chen from the South Coast Chinese Cultural Assn. Some Irvine residents drive to places with strong Asian populations like Garden Grove, where they can find small clinics with physicians and nurses who speak their languages.

And part of the downfall of Irvine Regional may have been the competition from third generation Chinese Americans who studied medicine and opened practices nearby, she added.

There, patients might find doctors who understand the formality and respect that can be conveyed by handing over forms with two hands, for example.

Hoag has apparently thought about this.

“How you present documents to certain cultures is important,” said Braithwaite.

The communication, or lack of it, can run both ways.

A patient might not admit to her doctor she doubts a rehabilitation plan will mend her hip replacement, if it’s customary to defer to medical authority. Then, when she goes home, she wouldn’t follow through on the directions to exercise.

Such a physician would want to coax the patient to participate in the decision-making, says Vicki Mays, a professor of psychology and health services at UCLA.

“You’re very careful not to give dictates,” she said.

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HUMAN RESOURCES

Hoag administrators trained all their staff — from nurses to security guards — in cultural awareness. Hospitalists and emergency room physicians, those with the most patient interaction, have also learned about Irvine patients’ special cultural needs, Braithwaite said.

A job description for an intensive care nurse sought someone who has “sensitivity in caring for multicultural” patients. Already, Hoag evaluates employees on their cultural competency.

Irvine managers looked for staff members who could speak the languages, or who were at least steeped in Chinese, Korean or Iranian cultures.

“One of the best ways to make people feel comfortable is to have people from those backgrounds and people who speak those languages,” said Gwen Yeo, a Stanford University researcher who focuses on geriatric care and Asians.

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CHANCES OF SUCCESS

Whether Hoag can make Chinese and Korean-Americans feel like they’re in Asia is unlikely. But the administrators have certainly tried to bridge any differences between Eastern and Western medicine.

“I don’t think there was a complete understanding of the differences of the communities,” said Smith, the vice president for facilities. “We became aware it does have special needs.”

Perhaps bigger considerations are nuts-and-bolts issues like insurance coverage or specialized equipment.

“I think once our people have the needs, it doesn’t matter what organization operates there,” said Chen, who gave birth in the building.