The ethics of quality: Is there a problem?
The ethics of quality: Is there a problem?
International group urges shared codes of ethics
Adverse medical events, falsifying data under orders, covering for an impaired physician. Where does the quality manager draw the line and balance sensitive situations with personal ethics?
The pressure is on these days to report medical errors, incompetent or impaired physicians, and dangerous situations involving outdated equipment. But what if administration is reluctant to deal with a potentially embarrassing or damaging incident?
Martin Merry, MD, health care quality consultant and associate professor of health management and policy at the University of New Hampshire in Exeter, has strong opinions about how all this is shaking out. "If a quality manager comes up with a problem that needs to be reported, and the administration doesn’t want to hear about it, it won’t be known. If the attitude espoused by the administration is that they don’t want to hear about bad news, quality managers pick up on it. And the institution’s legal advice will almost always be to cover up and keep quiet. They have to defend the case if it comes to a lawsuit, and the less information out there, the better."
For Lee Holmberg, MA, CPHQ, president of the Michigan Association for Healthcare Quality in Dearborn, the situation is a little easier. His institution reports incidents to the State Department of Consumer Affairs. "Michigan tort reform requires that seven classes of licensed health care providers be subject to reports of any deviation," he explained. "We report incidents of this kind directly to the state, making sure all our ducks are in a row and that we’ve done our part in providing the individual in question with the backup help necessary."
He explains that Michigan laws offer a protective umbrella related to peer review that gives health care administrators the freedom to deal with medical incidents with the state regulators.
So what about the federal regulators?
"You don’t want an accrediting agency that’s determining your reimbursement to necessarily be privy to your contacts with state agencies," Holmberg says. "But when the federal regulatory agencies come in for review, they are welcome to go through files on all physicians and other individuals, where they will then find the paperwork on any difficulties with doctors or personnel. If they ask me direct questions, I am happy to answer directly.
"But I believe in privacy for individuals," he says. "I would never want to violate those principles. When a rule states that a physician must not have moral turpitude,’ it’s too vague to even be a rule. How do you define something like that and apply it to an individual?"
But how often is an incident actually reported? Not often enough.
"Employees need to have a nonpunitive method of reporting," says Denny Thomas, director of risk management at St. Joseph Hospital in Marshfield, WI. Thomas also serves on the doard of directors of the American Society for Healthcare Risk Management (ASHRM) in Chicago.
The best route to go is to be honest’
Merry sees a new world coming regarding all this. He recently attended a conference sponsored by Irving, TX-based VHA Inc., titled "Building Systems That Do No Harm."
"[The conference] specifically addressed the patient harm that has been caused and the ethical situation for hospital leadership," he says. "All speakers agreed that incidents need to be explained to patients and their families. It’s only the right thing to do. The best route to go is to be honest with our errors and report them and share them with the patients and families. The moral and ethical need of the institution is to be up front. We don’t have to overdivulge, but a straightforward statement is certainly best with apologies and the offer of a settlement if that’s an issue."
ASHRM’s membership brochure indicates that members be responsible for educating physicians and other employees on the following matters, among others:
• risk management issues;
• utilization review;
• quality management;
• reporting risk information to committees and/or boards;
• risk/liability exposures;
• sentinel risk events.
The code of ethics for the Skokie, IL-based National Association of Healthcare Quality requires "personal accountability and moral obligation to all customers served." Quality managers must agree, among other things, to seek the trust and confidence of all customers; respect all laws and avoid involvement in any false, fraudulent, or deceptive activity; and use their expertise to inform employers or clients of possible positive and negative outcomes of management decisions in an effort to facilitate informed decision making.
But these are rules that affect just the risk and quality managers. What about administrators who take exception to some of their reports and activities?
"If risk management is dealing with a situation that makes the administration uncomfortable, I always have a third party come in and provide a risk assessment without bias," says Thomas. "This can be an insurance carrier or other assessor."
There are many people and machines in a hospital that can affect patient care. What about the complicated medical equipment in each unit that is constantly being upgraded and changed?
Holmberg says, "It’s imperative to me that everyone have competence and mastery before you set them loose with these machines. In a world of continuing quality improvement, it’s important to know that everyone’s competent. We extend our quality improvement program to everyone, from floor sweepers to administrators."
But there can be temptation or pressure to disguise deficiencies that would raise the eyebrows of surveyors, as well as to ignore quality problems and "adjust" written records to make them more compliance-friendly.
"It requires a cultural change," Thomas says. "People intend to provide care. It’s not their intent to make a mistake, but are they feeling free to report it without fear of retaliation?"
Impaired physicians present special problems
Then there is the case of the impaired physician. Hospital culture often encourages those who work with the doctor to simply look away. After all, it’s a doctor. The doctor mustn’t be embarrassed publicly. The doctor is able to make his own decisions about his behavior. The doctor is a well-known, well-loved public figure.
Holmberg says it may be just luck, but he’s only dealt with two incidents of physician drug or alcohol impairment in 30 years.
"This shouldn’t have to be an issue any longer," Thomas insists. "Impaired physicians should not be looked upon any differently than if they were an impaired food service employee. There are employee assistance programs and state-sponsored impaired physician programs. Five years ago, these situations would have been put under the carpet and cautiously ignored. But today, patient safety is so much in the forefront, plus corporate compliance, that any employee can report a situation like this by calling a hotline and remaining anonymous."
Holmberg says the Joint Commission is now doing newspaper reviews before surveyors go into an institution. "They search the news to see if there’s been any mention of negative episodes that might be sentinel events or concern medical staff," he explains. "It’s actually a smart thing to do. Then they can be more objective and ask more specific questions during the review process."
Administrators lack a code of ethics
At issue is the absence of a general code of ethics for all health care situations. If a risk or quality manager today sees an unsafe situation, he or she may be obligated to report it by the ethics code of a professional association. But there seems to be no written code requiring hospital administrators to act in a similar fashion.
This puts the quality and risk management people in a bind. Do they forward the report to the proper regulatory agency and risk losing their jobs, or do they quietly ignore the situation?
"Medicine’s dirty little secret," says Merry, "is that we prefer not to divulge. We’re in a watershed period now, coming from where we weren’t as forthcoming as we should be and moving toward enlightenment about producing systems to reduce the error rate as much as possible."
Last year, a working group of 15 health care leaders, including physicians, nurses, health care executives, academicians, ethicists, a jurist, an economist, and a philosopher, representing four nations (the United States, the United Kingdom, Mexico, and South Africa) met in Tavistock Square in London to discuss this very issue. They call themselves the Tavistock Group.
In an article in the Annals of Internal Medicine (1999; 130:143-147), members of the Tavistock Group published the group’s draft code of ethics. "Many groups of professionals that give and affect health care have established separate codes of ethics for their own disciplines, but no shared code exists that might bring all stakeholders in health care into a more consistent moral framework," the article says. Key points from the Tavistock Group’s draft code of ethics are summarized as follows:
• Cooperation with each other and those served is imperative for those working within the health care delivery system. Only with cooperation can health care delivery systems produce optimal outcomes and values for individuals and society.
• Each professional group involved in health care delivery must recognize and acknowledge ethical precepts and principles and promote a culture of ethics within its own membership. All professionals involved in health care delivery must collaborate with each other for the benefit of the patient and the public health in a manner that respects the ethical principles of professionalism and health care.
• Maintaining ethical principles must not be confused with rigidity or defensiveness over roles and actions. On the contrary, knowing the boundaries and respecting the integrity of principles allows individual health care workers to move among groups and operate effectively according to the requirements of various roles.
• All persons involved in the health care system must be committed to developing and applying the specific skills needed to work creatively in the presence of interpersonal and intergroup tensions.
• Patients and families bring their individual experience, capabilities, motivations, and expectations to the health care delivery system, along with their illnesses, their needs, and their bodies.
• Individual clinicians have the obligation to support and participate in improvements that reduce costs and to suggest how the money and other resources saved could be reinvested to accomplish better care for patients.
• Individual clinicians should not impede improvements in patient care because the financial implications of the improvements may affect them adversely.
• Individual clinicians have the obligation to change practices that may serve their interests but are costly to the system as a whole.
• All who work in the health care delivery system have the obligation to share ideas about "best practices" and to learn continually from each other.
The authors note that theirs is not a finished work but a draft to "elicit comment, critique, suggestions for revision, and, especially, ideas for implementation."
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.