Module VIII

Hello Everyone, well this week the topics I came into contact with through assignments were universal precautions as well as the importance of ethical health care executives. The discussion on posting discussed if health care staff should be made aware of patients that are diagnosed with HIV and TB. My first thought was yes since not everyone can be perfect at all times with universal precaution and it would ensure that everyone took that extra step. Also, if they come in direct contact don't they have the need to know? Even though as a staff member I would probably like it looking at it subjectively I realize that it really is not good for the organization as a whole. Like with many things if you lighten up on some things it may reflect the organizations views on other things. Protected health information is really going to be a priority especially in the future. As technology advances and persons find new ways for identity theft, medical identity theft and fraud hospitals cannot afford to be lackadaisical about anything. What really made me change my mind is that many HIV infected patients do not know and have not been tested yet. If staff relied on medical charts to warn each other to take precaution they would be putting themselves at major risk.

This week the topic of global warming and industries contributing to reduce their impact environmentally came up with various fundraising concerts. Is the health care industry really putting this as a priority? Are professionals really putting in effort to find ways to lessen their consumption? Most health care executives would state that there simply is not the money. However, often the biggest impact can be found from the smallest of activities. Environmentalists always advocates the impact of small changes in the daily routines of individual citizens to positively impact the environment. Are health care companies advocating the same idea among their facilities?

Finally, I do agree with the text that the ethics of a manager plays a great role often sometimes in his or her efficiency and efficacy. I think that staff often take cues from manager whether by the tone of his or her voice or through actions on whether to take certain policy seriously. Accordingly, impairment of a manager can almost bankrupt any trust or respect the manager might have gained. On another note, in terms of what attributes makes good leaders, managers in my facility often say that the best leaders are good readers. This means that those who lead well are often the most familiar with current events, theories and are self motivated to keep their devotion to ehtics strong.

Module VII

I've recently seen a great movie that discusses not only the evolution of health care but also health ethics. "Something The Lord Made" is a movie that chronicles the career of a black medical lab assistant that contributes to a major portion of another prevalent white physician who worked as the head of surgery at Johns Hopkins. Without any formal education, it shows how he went on to improve techniques that brought soldiers out of shock as well as techniques to perform the first heart surgery to treat the "blue baby" syndrome. From an ethical perspective it also chronicles a variety of ethical issues such as racial discrimination, animal testing, as well as whether or not heart surgery was an ethical area to research to begin with. This was due to a religious principle of keeping the heart intact. A principle I had never heard of since it is now less of an issue. I just thought how it was interesting how ethical dilemmas can go in and out of the public consciousness as technology and science advances. This movie also had an interesting point about animal experimentation. For instance, many dogs were used and killed through the research of the main character's career. Although I am generally against animal experimentation I couldn't help but think about the number of lives saved through his invention of heart surgery and the techniques to treat patients with blue baby syndrome and those who go into shock from blood loss.

In my last mini paper I actually stumbled upon a relatively new ethical phenomenon occurring in the workplace. I originally was going to do my paper on theft in the workplace and how it can force many companies into bankrupt. During my research I learned about medical identity theft and its very dangerous effects. Medical identity is the use of another person's name or insurance information to receive health care, interceptions of reimbursement for actual or falsified charges. For example, a doctor could write you a prescription during your stay in a hospital for narcotics and pick it up himself. Although this sounds like it only has financial repercussions it can also have deadly medical consequences. By changing information on your medical record for illegal reimbursement or the access to certain health goods or care, this false information could lead to serious medical errors. I would encourage everyone to look into this issue and stay on top of their health records, payment history with their insurance provider as well as their credit history.

Module VI

With all of the papers and discussion postings lately I have stumbled upon some interesting subjects, especially Amendment 8. I thought it might be an unusual topic to cover since it is not too often that legislation is an ethical issue but it did have some interesting parameters. One of the most interesting points I found was that the general public was slightly misled by its description on voting day. I remember voting during this election and if I had not known the details through my professors of what it would really mean to Floridians I probably would have voted for it. This makes me concerned about what other policy I have voted for thinking that it would produce benefit for the community. When the ballot was worded it was very one-sided stating that physicians with three incidents of medical malpractice incidents would be revoked of their license. However, what did it mean by "incident" or "physician"? However, why only target physicians? Why not chiropractors, alternative medicine practitioners, physical therapist etc.? I did not know this but the language was so ambiguous that there was a temporary injunction on it. Unfortunately, it did not last long. Some have even referred to this amendment as the amendment of unintended consequences.

Has Amendment 8 really produced any benefit for the community? So far the only results have been physicians leaving the state, an increase in medical malpractice insurance and more cases being settled out of fear. One of the worse things that both Amendment 7 and 8 have produced is a paranoia for physicians playing it safe. Since patients know that physicians will settle most of the time it won't encourage physicians to come clean about mistakes willingly. However, as we all know, the best policy to have when mistakes are made is an open communication policy where staff can learn from mistakes and patients are apologized to. Is the state encouraging this with Amendment 7 and 8?

This week module discusses the ethics of competition. In most cases competition is healthy for health care in that it forces facilities to improve quality and lower its unnecessary costs. However, what about the non-profit hospitals whose main consumer is the indigent? The Orlando Area in particular has so many hospitals that are in a constant state of competition. Are they considering the effects on the hometown safety net?

Module V

In the Hoffman-Nelson book this week they discuss institutional advanced directives as well as the executive's role in clinical matters. I absolutely agree that advanced directives/ power of attorneys should be encouraged no matter what your health status is. However, why wait until the pre-admissions process at the hospital? I think that persons should be encouraged to write advanced directives as they are encouraged to keep an updated will. Physicians could take an active role in this initiative by educating their patients on the value of it especially when treating them for a chronic disease. One interesting point I saw was from this article http://www.msnbc.msn.com/id/7289351/page/2/ where it discusses what Americans have learned from the Schiavo case and how it was a missed opportunities for other health care groups (organizations for Alzheimers, Parkinsons, Huntington's disease etc.) to speak up on the topic and debate the real ethical issues to inform the public.

As far as institutional advanced directives are concerned, as a patient I would be concerned. If an institution has broad guidelines based on general situations I would be worried that they would not be flexible enough for situational scenarios and I might be limited certain care. Medicine is as much of an art as it is a science. Although I agree that having some guidelines in place to prevent extraordinary treatment that has little chance of working is financially sound and fair to the greater community it does technically limit access. It reminds me of facilities self-imposing rationed health care. If a patient has the right to refuse care should they have the right to ask for more care? Patients often defy odds and one can never really predict exactly what will happen in response to treatment. Last week there was a man in the news that had woken up from a coma lasting several years. What helped revive him? Standard care for pneumonia. When he first received the care would it have been seen as a complete waste of resources? Absolutely. However a woman got her husband back.

Finally the next section was about how much involvement should a manager have in clinical matters. I think it is very important for managers to have enough clinical knowledge as possible. Just because a manager may not be able to do a procedure or treat a patient does not mean he or she does not have an opinion about it ethically. In the long term care facility I work at managers make informal rounds daily and attend clinical staff meetings. I think that the more familiar clinical staff are to managers the more effective managers can be. Also, the more clinical meetings managers observe the more respect they will receive from clinical staff which can facilitate open communication regarding ethical issues.

Module IV

Hello Everyone,

I thought this week's case on gender discrimination was very interesting. This is because it's not blatant sexual or gender discrimination but somewhere in between. Which I suppose is what ethics is all about. In this case a CEO works with an attractive woman in a fellowship for the company where they work long hours and take trips to conventions in ideal locales. Is this ethical for a married CEO? I think not. If I were the board I would be more concerned about his actions leading up to the fellow being denied a job since there is never a guarantee for a job for fellowships.

I think the CEO crossed the line by working so closely with the fellow to begin with. In normal circumstances the fellow would have mostly worked with other staff and presented her findings on a regular basis and met with the CEO occasionally to discuss certain options. Having a person of power continuously having a subordinates of another sex work late hours by themselves is unprofessional and should raise suspicion to other staff. Also, why was it only the CEO and the fellow going to these conferences? Surely other staff could have benefited and deserved going to conferences in prime locations. From the story it seems that the CEO intentionally found conferences in romantic settings to bring the fellow on purpose and the fact that they were educational was a plus. Even if nothing happened it is still not behavior suiting an ethical CEO. The fellow was in a vulnerable situation since she was very ambitious, anxious to learn and grateful to a mentor. Although no explicit sexual coercion occurred implicit coercion to spend time with him did.

As far as sexual harassment goes, if she was a man she would have gotten a job due to her accomplishments in her fellowship. Couldn't the CEO simply have placed her in another department or another location of the hospital? Should employees be punished because managers are attracted to them? On an organizational scale I'm afraid this CEO may lose a lot of trust from their employees, especially female employees.

This case brings up a great lesson however. The best way to avoid unethical temptation is simply to not allow yourself to be put in that kind of situation. One must identify ethical slippery slopes ahead of time and place boundaries and rules to allow all employees to be treated equally and be rewarded on unbiased merit. A couple of weeks ago I heard of one employer that refused to have a couch in his office or in the work area. Why? To not let himself or his staff be put into a kind of situation that could facilitate unprofessional behavior. In an office a majority of staff are either married or in a relationship and most companies have policies on inter-office dating. In my opinion the couch policy is a prime example of the lesson learned in this case.

Module III

This week's reading assignment covers a good amount of topics. With institutional resources they of course mentioned a national public health system and access to care. I think this of course will always be a permanent topic of much debate as long as our health care system remains as is. http://www.burtonreport.com/InfHealthCare/BritNatHealthServ.htm is a link to an online British journal regarding their views about the English National Health Service as well as the idea of the United States emulating a similar structure. Basically they believe that "standing patiently in line for rationed goods" is not in the American mindset. I agree. Considering all the moaning and complaining that currently exists over taxes. Can you imagine the degree of discord if taxes were to be raised to a level to support a national health system?

Currently, most medically necessary interventions are available to us. For the medically indigent you are covered by Medicaid, those stuck in between have the "safety net" and no one is denied life care within emergency situations. Would Americans stand by while those who need medically necessary surgeries were denied due to rationing under the new system? Americans work for and basically expect nothing but the best. Will Americans be willing to wait patiently for their grandmother to wait a few months to have her tumor removed because a ration based limit has been met for that type of surgeries that year? Doubtful.

However, I don't think a national health system is the only answer. There are many alternatives such as initiatives that require employers to distribute some level of health insurance or monies used for health care. Right now a great portion of the uninsured are the "working poor" or those who make enough not to qualify for Medicaid but do not make enough to buy insurance or have the ability to save enough for private pay. There could always be a government program that provides insurance to those who qualify, based on their income, for a insurance program where premiums were affordable. However, that's just me. I remember Dr. Unruh used to say that HSA's wouldn't really work since those who are healthy would opt for them leaving the very sick to stay with insurance companies. Inevitably this would skew the case mix for insurance companies and raise premiums so high that the very sick would suffer which is obviously not the aim of health care.

Module II

This week I reviewed the section on medical errors. This case really reminded me of the Dana-Farber Cancer Institute. It was also a highly regarded research hospital that came under much public scrutiny after a lack of communication led to medical errors and consequently a patient death. Within a Capstone assignment we were instructed to come up with a plan on how we would deal with it as an administrator. As any health care lawyer will tell you a physician's relationship with the patient often determines whether litigation will follow. Also by example of John Hopkins, it is always best to have open communication with the family when medical errors occur.

In one instance a family whose daughter died at Johns Hopkins from a medical error teamed up with the hospital to develop medical prevention techniques. Although this may sound unusual the family, instead of blaming the hospital for the error and harboring ill will, worked together with Johns Hopkins and quietly settled out of court due to the hospital's open demeanor in explaining the cause of their daughter's death. So with open communication the hospital turned a liability into a strength.

Below is an article that shows how having open communication about medical errors can actually be a risk management technique. http://web.ebscohost.com.ucfproxy.fcla.edu/ehost/detail?vid=12&hid=106&sid=399d8d56-acf8-4345-a595-7f1a5042c695%40sessionmgr108
Here David Studdert Melio, M., Gawande, A., Brennan, T.A., and Wang, C.Y. also state that such communication is the only way effective preventive strategies can take place or be constructed in the first place.

Getting back to the case in the Perry book, this question definitely has legal implications. I would consider withholding information about medical treatment they are receiving a definite violation of informed consent. This is due to the fact that chemo is not one isolated incident but an on-going treatment lasting over years so shouldn't the patient have a right to informed consent for each and every treatment? Physicians should always note that patients may not always be giving the full details about how they are coping with the chemo from treatment to treatment. Thus they cannot rely on themselves to catch something adverse reactions to overdoses. One main lesson from the Dana Farber case is that even the most gifted and close group of physicians and nurses cannot be trusted to catch everything.

In my opinion in cases like these..."the truth will set you free". This is a great burden for staff and physicians to carry by keeping secrets and definitely does not set the correct tone and culture for the organization. If incidents like these are let slip by the organization as a whole will simply keep spiraling down until something devastating happens. If some of the best hospitals in the country are able to step up and admit mistakes and actually benefit from it, open communication should not be a scary proposition for health care administrators. Trust is something one can rarely win back especially when it regards one's health.

I will end with an example from my life. This Thursday, we had a home health nurse inform us that her client was not in her room and other staff had commented that the last time she was seen was outside in the garden close to the exit. This resident is also under watch for having dementia problems and administrators feared that she had wandered out into the city's downtown streets. If the company had done what those in the case had done they would have had followed procedures and searched for 15 minutes and then called the police. However by calling the family first they were able to find out that the granddaughter had taken the resident to another floor to visit friends. Open communication about possible errors can often be the key to the error's solution.