Utilizing Community-based Participatory Research Principles in a Safety-Net Hospital to Develop a Research Partnership.

Research at safety-net hospitals may require additional planning to ensure the ethical conduct of research with vulnerable populations. This report discusses application of the principles of community-based participatory research and bioethics to establish a research partnership with a safety-net hospital in the southern U.S.

Hospitals' Obligations to Address Social Determinants of Health.

Federal health care reform has expanded medical insurance to millions of people, altering the role that hospitals play in improving community health. However, current federal and state community benefit policy is an ineffective tool for ensuring that hospitals address the social determinants of health afflicting their communities. Policy shifts and other incentives that promote improved population health outcomes can encourage health care organizations to do the same.

Where Hospital Boards Often Fail: Auditing Leadership Performance.

Hospital boards address quality of care and patient safety as well as financial performance through long-accepted practices. By contrast, a hospital's administrative operations and institutional culture are not usually subject to such detailed scrutiny. Yet, despite a healthy bottom line and patient commendations, hospital personnel can be underperforming, burdened with poor morale, and suffering from less-than-optimal leadership, unwarranted inefficiency, and ethically questionable management practices. The resulting employee dissatisfaction or disengagement can affect productivity, quality, turnover, innovation, patient and donor attraction and retention, public image, etc., and can be missed by an unsuspecting board. While boards do not scrutinize most administrative operations, they do examine financial performance, through review of the independent auditor's Management Letter. Designed to help the chief financial officer (CFO) improve the efficiency and integrity of the hospital's financial systems and to recommend improvements to the board for implementation (rather than to assess the CFO's performance), the Management Letter has no equal with respect to a comparable evaluation of the hospital's administrative performance and workplace culture. When, as is often the case, there is only superficial review of the chief executive officer, the board has no source of analysis or recommendations to improve the hospital's institutional environment. In this Invited Commentary, the authors suggest a methodology to provide such a review, leading to a Leadership Letter, and discuss its utility for both nonprofit and for-profit organizations.

Investigating motivating factors for sound hospital waste management.

UNLABELLED: Sustainable management of hospital waste requires an active involvement of all key players. This study aims to test the hypothesis that three motivating factors, namely, Reputation, Liability, and Expense, influence hospital waste management. The survey for this study was conducted in two phases, with the pilot study used for exploratory factor analysis and the subsequent main survey used for cross-validation using confirmatory factor analysis. The hypotheses were validated through one-sample t tests. Correlations were established between the three motivating factors and organizational characteristics of hospital type, location, category, and size. The hypotheses were validated, and it was found that the factors of Liability and Expense varied considerably with respect to location and size of a hospital. The factor of Reputation, however, did not exhibit significant variation. In conclusion, concerns about the reputation of a facility and an apprehension of liability act as incentives for sound hospital waste management, whereas concerns about financial costs and perceived overburden on staff act as disincentives. IMPLICATIONS: This paper identifies the non economic motivating factors that can be used to encourage behavioral changes regarding waste management at hospitals in resource constrained environments. This study discovered that organizational characteristics such as hospital size and location cause the responses to vary among the subjects. Hence a policy maker must take into account the institutional setting before introducing a change geared towards better waste management outcomes across hospitals. This study covers a topic that has hitherto been neglected in resource constrained countries. Thus it can be used as one of the first steps to highlight and tackle the issue.

Culture, compassion and clinical neglect: probity in the NHS after Mid Staffordshire.

Speaking of the public response to the deaths of children at the Bristol Royal Infirmary before 2001, the BMJ commented that the NHS would be 'all changed, changed utterly'. Today, two inquiries into the Mid Staffordshire Foundation Trust suggest nothing changed at all. Many patients died as a result of their care and the stories of indifference and neglect there are harrowing. Yet Bristol and Mid Staffordshire are not isolated reports. In 2011, the Health Services Ombudsman reported on the care of elderly and frail patients in the NHS and found a failure to recognise their humanity and individuality and to respond to them with sensitivity, compassion and professionalism. Likewise, the Care Quality Commission and Healthcare Commission received complaints from patients and relatives about the quality of nursing care. These included patients not being fed, patients left in soiled bedding, poor hygiene practices, and general disregard for privacy and dignity. Why is there such tolerance of poor clinical standards? We need a better understanding of the circumstances that can lead to these outcomes and how best to respond to them. We discuss the findings of these and other reports and consider whether attention should be devoted to managing individual behaviour, or focus on the systemic influences which predispose hospital staff to behave in this way. Lastly, we consider whether we should look further afield to cognitive psychology to better understand how clinicians and managers make decisions?

[Healthcare occupations are "different"]. / Gesundheitsberufe sind "anders"

Healthcare requires careful coordination of several occupations. In order to attain the best possible result, including effectiveness and cost-efficiency, the specific expertise of each of these occupations must be clearly defined. Healthcare occupations, physicians and nurses, are indeed professions as opposed to mere "jobs". They are concerned with living but ill human beings and not with things. Reliance on a personal capacity of judgment is a decisive aspect of professions. Healthcare professionals perform best if they are granted specific independence relative to their work.

Unpredictable drug shortages: an ethical framework for short-term rationing in hospitals.

Periodic and unexpected shortages of drugs, biologics, and even medical devices have become commonplace in the United States. When shortages occur, hospitals and clinics need to decide how to ration their available stock. When such situations arise, institutions can choose from several different allocation schemes, such as first-come, first-served, a lottery, or a more rational and calculated approach. While the first two approaches sound reasonable at first glance, there are a number of problems associated with them, including the inability to make fine, individual patient-centered decisions. They also do not discriminate between what kinds of patients and what types of uses may be more deserving or reasonable than others. In this article I outline an ethically acceptable procedure for rationing drugs during a shortage in which demand outstrips supply.

[Precariousness, DRG's and health planning: pilot study at the Lariboisière hospital in Paris]. / Précarité, tarification à l'activité et planification sanitaire et sociale: étude pilote à l'hôpital Lariboisière de Paris.

OBJECTIVES: This paper considers the specific administrative procedures set up by managers of public healthcare establishments and those responsible for health and welfare policies to care for low-income pregnant women for whom 100% of the "price per act" (T2A) is refunded. What are the limitations and what improvements can be suggested? PATIENTS AND METHOD: The results are based on an analysis of data from semi-structured interviews, legislation and documents. RESULTS: The State, health insurance systems, public health establishments, local authorities, charities and outpatient services are involved in handling low-income parturients in different services and different establishments, both locally and regionally. A health and welfare policy comprising specific, coordinated actions and measures has been developed. The T2A "price per act" system may threaten its survival: the limited number of front-line facilities is often saturated and demand is increasing, treatment is often reduced to reactive management leading to unwanted readmissions, ethics are sometimes called into question and there is a risk of patient selection. DISCUSSION AND CONCLUSION: This pilot study provided some encouraging information but also indicated the limitations of the approach adopted. However, it was still of interest to see whether it was possible to use this approach, which did not require considerable resources, to reveal useful markers. This appeared to be the case. Regional Health Agencies (ARS) and local authorities could support the system. Additional funding is needed.

Risk managers, physicians, and disclosure of harmful medical errors.

BACKGROUND: Physicians are encouraged to disclose medical errors to patients, which often requires close collaboration between physicians and risk managers. METHODS: An anonymous national survey of 2,988 healthcare facility-based risk managers was conducted between November 2004 and March 2005, and results were compared with those of a previous survey (conducted between July 2003 and March 2004) of 1,311 medical physicians in Washington and Missouri. Both surveys included an error-disclosure scenario for an obvious and a less obvious error with scripted response options. RESULTS: More risk managers than physicians were aware that an error-reporting system was present at their hospital (81% versus 39%, p < .001) and believed that mechanisms to inform physicians about errors in their hospital were adequate (51% versus 17%, p < .001). More risk managers than physicians strongly agreed that serious errors should be disclosed to patients (70% versus 49%, p < .001). Across both error scenario, risk managers were more likely than physicians to definitely recommend that the error be disclosed (76% versus 50%, p < .001) and to provide full details about how the error would be prevented in the future (62% versus 51%, p < .001). However, physicians were more likely than risk managers to provide a full apology recognizing the harm caused by the error (39% versus 21%, p < .001). CONCLUSIONS: Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology. These differences may create conflicts between risk managers and physicians regarding disclosure. Health care institutions should promote greater collaboration between these two key participants in disclosure conversations.

[Moral responsibility of hospital management]. / Das Krankenhausmanagement im Spannungsfeld medizin- und unternehmensethischer Prinzipien.

The self-concept of hospitals today includes the role of service providers, and so they act accordingly. This attitude is chiefly held by hospital administrators. It means that at management level there is a shift of values toward business ethics. However, hospital management is responsible not only for the business aspects of the hospital but also for the provision of adequate medical care to patients. Therefore, hospitals as service providers must be governed by the principles of medical as well as of business ethics. These principles, although from different areas, can be made to largely coincide, but can also lead to divergent positions within a hospital. The result is what within the scope of medical ethics, too, is experienced as a conflict of principles, e.g., the principle of beneficence versus the principle of autonomy. A reconciliation of such divergent moral positions can often be effected by analyzing the actual conflict situation and thus reaching consensus. The conflict between the principles of medical ethics and business ethics takes place chiefly within the sphere of activity of those providing medical and nursing care. As a consequence, a necessary business decision taken by the management to improve the productivity of medical and nursing activities can lead to serious deficits on the staff side. In terms of business ethics, this is a lack of beneficence toward individual staff members that are perhaps overtaxed, and at the same time, in terms of medical ethics, a potential lack of beneficence toward hospital patients is implicitly accepted. In general, management has the responsibility for bringing about, in the day-to-day operation of a hospital, a plausible reconciliation of the ethical principles of two spheres of activity that are only apparently independent of each other.

Managing the conflict between individual needs and group interests--ethical leadership in health care organizations.

This paper derives from a grounded theory study of how Medical Directors working within the UK National Health Service manage the moral quandaries that they encounter as leaders of health care organizations. The reason health care organizations exist is to provide better care for individuals through providing shared resources for groups of people. This creates a paradox at the heart of health care organization, because serving the interests of groups sometimes runs counter to serving the needs of individuals. The paradox presents ethical dilemmas at every level of the organization, from the boardroom to the bedside. Medical Directors experience these organizational ethical dilemmas most acutely by virtue of their position in the organization. As doctors, their professional ethic obliges them to put the interests of individual patients first. As executive directors, their role is to help secure the delivery of services that meet the needs of the whole patient population. What should they do when the interests of groups of patients, and of individual patients, appear to conflict? The first task of an ethical healthcare organization is to secure the trust of patients, and two examples of medical ethical leadership are discussed against this background. These examples suggest that conflict between individual and population needs is integral to health care organization, so dilemmas addressed at one level of the organization inevitably re-emerge in altered form at other levels. Finally, analysis of the ethical activity that Medical Directors have described affords insight into the interpersonal components of ethical skill and knowledge.

Notions of just health care at three Swedish hospitals.

This article investigates what notions of "just health care" are found at three Swedish hospitals among health care personnel and whether these notions are relevant to what priorities are actually made. Fieldwork at all three hospitals and 114 in-depth interviews were conducted. Data have been subject to conceptual and ethical analysis and categorisation. According to our findings, justice is an important idea to health care personnel at the studied hospitals. Two main notions of just health care were found. The main idea was the notion of "equal treatment according to need", the basic idea being that differences in treatment should be justified by differences in needs. The competing idea that merit should affect the treatment received is occasionally encountered, the idea here being that patients, by acting irresponsibly, may no longer deserve to be treated strictly according to needs. In practice, priorities are made on grounds that only partly comply with the basic idea of justice in health care, as it is understood by staff at the studied hospitals. Exceptions are made due to regional differences, considerations of cost-effectiveness, economic incentives, tradition, the daily patient flow, research, private alternatives, patient influence and favouritism of health care personnel.

Ripple effect: ethics begin with the board.

Understanding and upholding the highest ethical standards has never had higher stakes for boards, but it often means choosing between several "rights."

Young teenagers providing their own surgical consents: an ethical-legal dilemma for perioperative registered nurses.

During the delivery of health care, ethical-legal problems are not uncommon and can be defined as situations that have potential legal consequences when equally compelling ethical reasons for and against a particular course of action are recognized and a decision must be made. Ethical-legal repercussions may occur when obtaining surgical consent from a younger teenager (defined as dependant and/or under 18 years of age). An ethical-legal dilemma arising from the case of a 14-year-old, run away girl, who had signed her own surgical consent for a cholecystectomy is analyzed. The concept of consent is discussed and related to an actual case study. The elements of a valid informed consent are identified, discussed and related to the case study. Using the MORAL model for ethical decision-making the ethical implications of this case are analysed. Possible legal repercussions are addressed and a risk management strategy (suggested policy and documentation protocols for the consent process) is proposed and evaluated.