Unethical Behaviour in the Workplace

Is it Bad Apples, Bad Cases or Bad Barrels?

A fascinating read on a topic close to my heart has been published by the Chartered Institute of Personnel and Development. 

https://www.cipd.co.uk/knowledge/culture/ethics/ethical-behaviour#gref

This summarises the research around unethical practices in the workplace, what causes it, and how to address or prevent it. the authors ask which of the following factors give rise to unethical actions"

1. 'Rotten apples’: to what extent is unethical behaviour the result of individual choices? 
2. ‘Bad barrels’: to what extent is it due to systemic, organisation or industry-wide problems, in particular organisational culture or ingrained norms of behaviour?
3. ‘Sticky situations’: to what extent is it due to the difficult or compromising nature of decisions that people face?

Highly recommended reading.

 

Surgical Mortality in Europe

A fascinating paper just published in the Lancet, outlining rates of mortality up to 7 days post operatively across 28 European countries. Data on over 46000 patients was collected. Crude mortality ranged from 1.2% of all cases in Iceland to >20% in Latvia. When adjusted for confounding variables, e.g. smoking, COPD etc, there was a TEN FOLD difference between the best and worst performing systems.

"When compared with the UK, the recorded mortality rates for Poland, Latvia, Romania, and Ireland were higher even after adjustment for all identified confounding variables. This pattern could relate to cultural, demographic, socioeconomic, and political differences between nations, which might affect population health and health-care outcomes."

However there may be other explanations, including the size and volume of surgical units, availability and expertise of intensive care, staffing, training and use (or lack of use) of approaches known to reduce morbidity and mortality such as pre-operative briefings (Gawande and others), appropriate antimicrobial prophylaxis and VTE prophylaxis. Regardless of the cause, yet again we see evidence of huge variation. Time to start learning why this exists. 
 

Escape Fire

Check out the trailer for this movie. Escape Fire, an indepth look at the US health care "system", but lessons for all of us. Title is taken from a great speech by Dr. Don Berwick

HROs

Tweeted by @peterlachman who is attending Risky Business, a link to a v useful resource about high reliability organizations. See here.

Waste and overuse

I read this paper recently and then reread it (subscription probably required); this I think is destined to become a classic. It touches on subject matter to which I have alluded in recent posts, Quality is goodness, Choosing Wisely and Waste and healthcare costs. The authors set out to examine the extent to which overuse of healthcare resources, defined as inappropriate diagnostics, treatments and medications has been studied. The results were striking in a very negative sense. Medline was searched for a period of 21 years, and a total of 172 papers were found which examined some aspect of overuse:

"We identified 172 articles measuring overuse: 53 concerned therapeutic procedures; 38, diagnostic tests; and 81, medications. Eighteen unique therapeutic procedures and 24 diagnostic services were evaluated, including 10 preventive diagnostic services. The most commonly studied services were antibiotics for upper respiratory tract infections (59 studies), coronary angiography (17 studies), carotid endarterectomy (13 studies), and coronary artery bypass grafting (10 studies)" 

In other words, 172 papers have sought to determine the extent of waste attributable to overuse (in the US healthcare system) out of >114,000 evaluated. Just to re-emphasise, some authorities estimate that waste contributes to 20-30% of US healthcare expenditure and we appear not to have even begun to systematically examine the extent of the problem. Even where the work has been done, it appears the papers are limited to a few main areas, including angiography, CABG, cartotid endartectomy, antibiotics for respiratory infections etc. Not that it is an easy thing to study, but surely government funding agencies should be in these challenging times insisting that more efforts be put into studying these areas rather than focussing on the next addition to our medical arsenal.

A Note to My Younger Colleagues. . .Be Brave

I was searching for a couple of papers by Harlan Krumholz today for another post and came across this piece just published. I found it inspiring. He writes about the difficulties and challenges of standing against the status quo, even when, especially when the vested interests as they mass in opposition seem to brook or tolerate no opposition. A few choice passages (underlined by me):

"Unfortunately, our profession does not often reward those who question dogma. In fact, there are many episodes throughout the history of medicine and science in which truth was resisted and dogmatic beliefs, however poorly supported by evidence, were imposed by those in a position to do so. If we are to accelerate innovation in medicine, eliminate waste- ful practices, and improve the depth and effectiveness of how we care for patients, then there must be room to question traditional approaches and to introduce new and better ways of prevention, diagnosis, and treatment. We are now at that critical juncture.
When I entered medicine, I did not realize that there was such intense pressure to conform. But we learn early on that there is a decorum to medicine, a politeness. A hidden curriculum teaches us not to disturb the status quo. We are trained to defer to authority, not to question it. We depend on powerful individuals and organizations and are taught that success does not often come to those who ask uncomfortable questions or suggest new ways of providing care. 

I have grown to appreciate those who will stand up despite the risks or in the face of efforts to silence them. Promoting the best science and the best advocacy for patients and the public sometimes entails risk. Change does not come easily to a system and there is resistance to those who may seek to make the system safer, more effective, and more patient-centered through new ideas or the articulation of uncomfortable truths." 

He also quotes from Victor Montori, from Mayo Clinic who writes:

"I have struggled with this issue for years. Turns out that this is a common struggle for those who find themselves unable to stay silent in the face of waste, error, low integrity, or abuse.
If you find yourself with some time (not a lot), let me recommend Letters to a Young Contrarian by Hitchens.His argument that clarity emerges from conflict is compelling. And for conflict to emerge, ie for clarity to emerge, someone has to take a position. The question you ask is whether this should be you, now, and at this stage of your career." 

Read it and distribute widely. 

Quality is goodness

In the spirit of stealing shamelessly, I am going to plunder Anna Roths latest post from her blog. She summarises a talk by Dr. Don Berwick. Highlights include:

"Quality is Goodness"

"What do we need to do? This is the 2.6 trillion dollar question isn't it? Here is a list to help guide us.

1. Put patients first

2. Protect the disadvantaged 

3. Start at scale –move fast – go "all in"

4. Return the money

5. Act locally"

"The Ethics of Improvement

1. Professionals have a duty to help improve the systems in which they work.
2. Leaders have a duty to make 1. Logistical, feasible and supported.
3. No excuses for inaction on 1 and 2 are acceptable.
4. The duty to improve encompasses safety, efficiency, patient-centeredness, timeliness, effectiveness, and equity requires continual reduction of waste. The IOM six dimensions quality of are dimensions of goodness
5. Those who educate professionals have the duty to prepare them for improvement work."

Wow, in 25 plus years of training, working, and teaching, no-one has ever said to me there is an ethical duty to educate professionals for improvement. Self evident but an indication of why we are finding healthcare improvement to be so challenging. 

Anna is always worth reading. Follow her blog and twitter. 

Economics of improving quality

There is a constant tension in healthcare between the economic/ financial imperatives and the clinical demands. Not unreasonably, based on healthcare inflation around the world over the last 40 years, there is a belief that more (which for many people, clinicians and patients) healthcare is better healthcare. Those of us interested in quality believe that this is not always the case. However the quality people I believe have been remiss in not addressing the evidence base for what they do, or the economic benefits of improving quality. Followers of Deming believe unequivocally that improving quality drives down cost. Brent James firmly believes that improving quality in Intermountain has not only improved care but dramatically driven down costs. Hence the importance of this paper just published and free to access.

The authors aim was to systematically review comparative economic analyses of patient safety improvements in the acute care setting and they explored 15 patient safety conditions and six associated improvement strategies. They concluded that pharmacist-led medication reconciliation, the Keystone ICU intervention for central line-associated bloodstream infections, chlorhexidine for vascular catheter site care, and standard surgical sponge counts were economically attractive strategies for improving patient safety.

Great stuff, a lot more needed.

Choosing Wisely

A very interesting initiative has been undertaken by a large number of medical professional bodies in the US. Termed Choosing Wisely, 9 societies have each listed 5 procedures which they believe are overused, and which they feel need some consideration and discussion prior to being used. To learn more, check out IHI WIHI on May 17th which will discuss tis in more detail. As Churchill said about the US,


“You can always count on Americans to do the right thing - after they've tried everything else.”

Listen in, it;'s free and promises to provoke some thinking

Child Protection & Professionals

Anyone with a passing knowledge of the David Southall saga probably shivers. A very comprehensive account has just bene published in the BMJ here, which will only add I think to the fear that many professionals, especially pediatricians have when faced with child protection cases. As the article says, quoting the esteemed editor of Pediatrics, Jerrold Lucey, “There is something grossly wrong with the medical and legal system which allowed this to happen."

Empathy robots

ZDogg MD is a genius, cant vouch for his medical expertise, but as a comedian, he has few competitors, (ok a bit of an exaggeration). Check this video out if you are having a bad day.

Gawande and 200 years of surgery

A wonderful piece of writing from Medicines prose laureate. This comes from the NEJM 200th anniversary series and Atul Gawande writes about the history of surgery. My favourite paragraph,

"It would take a little while for surgeons to discover that the use of anesthesia allowed them time to be meticulous. Despite the advantages of anesthesia, Liston, like many other surgeons, proceeded in his usual lightning-quick and bloody way. Spectators in the operating-theater gallery would still get out their pocket watches to time him. The butler's operation, for instance, took an astonishing 25 seconds from incision to wound closure. (Liston operated so fast that he once accidentally amputated an assistant's fingers along with a patient's leg, according to Hollingham. The patient and the assistant both died of sepsis, and a spectator reportedly died of shock, resulting in the only known procedure with a 300% mortality.)"

First contact with Deming

According to Charles Kenney in his book, "The Best Practice" Dr. Paul Batalden first became aware of Deming and his work when he read an article about him in the New York Times. As far as I can ascertain, the article is here, well worth a read. From Batalden, it appears the Deming gospel was spread to Dr. Berwick. From small acorns, great oaks grow. By the way, The Best practice is well worth a read for all you healthcare quality junkies out there.

Waste and healthcare costs

Dr Berwick has written two pieces in which he makes the case that waste broadly defined accounts for 20-30% of US healthcare expenditure. JAMA article requires subscription here and Boston Globe piece here.

He defines waste as follows:

1. Over-treatment
2. Failures of care coordination
3. Failures in execution of care processes
4. Administrative complexity
5. Pricing failures, and 
6. Fraud and abuse

I can certainly see items 1-5 occurring in our system; whether fraud contributes a substantial amount, I just dont have the data. I am guessing failed IT implementation falls into category 4. Interestingly the Vanguard organisation has provided initial estimates based on preliminary work that what they term failure demand (which would certainly fit into category 1-4 above accounts for a very substantial proportion of healthcare activity), for an example see here. 

Interested in spreading QI?

A very useful resource, here, for anyone interested in implementing and spreading quality improvement in healthcare. Full of lessons learned and suggestion on overcoming barriers.

"they identified 10 key challenges to improvement that consistently emerged in the programmes evaluated:

• convincing people that there is a problem
• convincing people that the solution chosen is the right one
• getting data collection and monitoring systems right
• excess ambitions and ‘projectness’
• the organisational context, culture and capacities
• tribalism and lack of staff engagement
• leadership
• balancing carrots and sticks – harnessing commitment through incentives and potential sanctions
• securing sustainability
• considering the side effects of change.

Checklists Again.

If one wanted hard evidence that checklists are effective, read this piece in the New York Times about pharma companies using symptom checklists which allow potential patients to confirm their diagnosis which in turn may lead to the prescription of a drug made by that pharma company. Wonderful! Or maybe not?

The system is dead, long live the system

If you believe, as I do, that the current model of Western healthcare delivery is dying, I suggest you read this piece. Medicine is succumbing to the disease that infects all large human endeavors, the current structures seek to justify and build upon themselves. Even if done for the best of reasons, the usual solution sought from heath care workers is to build more of the same, buy more of the same, do more of the same. I see many parallels between the military industrial complex that worried Eisenhower, and our current medical industrial complex.