Workarounds in Hospitals Raise Ethical Questions

A disconnect between how an organization imagines work is happening and what staff feel they must do puts healthcare workers on potentially ethically shaky ground.

This is part one of a two-part interview.

Shortcuts. System fixes. Bending the rules. Whatever you call them, workarounds are a part of life for healthcare workers. But they can result in ethical concerns and questions.

When, if ever, are workarounds OK? And when are they not?

Nancy Berlinger, PhD, a research scholar at the Hastings Center, an independent research institution focusing on bioethics based in Garrison, NY, puts a shining light on this topic with her recently published book, Are Workarounds Ethical? Managing Moral Problems in Health Care Systems.

She says she began thinking about workarounds as she was speaking with healthcare professionals during talks for her first book.

"They themselves would talk a lot about workarounds," she says. "Sometimes they would say 'shortcuts' or 'fixes' 'bending the rules,' 'working the system,' 'cutting corners.' You'd hear a big range of things; 'tailoring the chart'…a large range of things. I would say, tell me, what do you mean? Tell me more about that."

What Hospital Leaders Don't Know about Clinical Workarounds

In a recent phone interview, Berlinger discussed her research on workarounds: What they are, when they're acceptable and when they're not, and how organizations can harness them to help create positive change. The transcript has been lightly edited.

HLM: What are workarounds and what are some that healthcare workers and leaders would recognize in themselves or their colleagues?

Berlinger: Workarounds are the umbrella term for a decision made, usually fast and under pressure, where the situation at hand does not fit the official rules for what you are supposed to do in that situation. Other phrases that someone might use are 'getting creative,' or 'improvising,' or 'doing it my way.' So there's a whole range of ways that people might characterize these situations.

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The reason they're of ethical concern—that there's a concern with regard to questions about right and wrong—is at least twofold.

One is because the system itself is usually the source of the pressure to create the workarounds: The basic disconnect, between [how] the organization imagines work is happening and what people feel that they're actually forced to do, usually under pressure to be efficient, to get the job done, and so on.

[Another is] that sometimes people feel that they have to work around rules that seem unfair. That a patient who needs something cannot get what they need because of a rule that may not be an organization rule, but might be a federal or state policy that makes it hard to provide something to that person.

There's a chapter in the book about access to healthcare for patients who are undocumented. [These] patients inevitably wind up in safety net systems. Because they are ineligible for a range of covered benefits that, ordinarily, low income people would be entitled to, it can put a lot of pressure of staff to say, 'Is there a way that we can possibly get you this even though you're not insured?'

It comes up in psychiatric settings; it comes up settings when people hit Medicare rules. People don't want to commit fraud or they don't want to break laws, but they are in a situation where the needs of the patient are going to be hard to meet because of the lack of some coverage mechanism.

And these are the consequences of policy decisions… made far, far away from the person at hand. Even a small adjustment in the way a doctor or nurse or social worker does their work could be linked to something that happened way upstream and far away from them.

HLM: Can you share some other examples of these workarounds? Do the people doing them feel like they're making a moral decision to do the right thing?

Berlinger: Yeah, exactly. People who work in safety net settings… know that many of the patients who they're caring for are low income, and yet they constantly face the consequences of some patients having no access to insurance or very limited access.

Let's say you were in a state where your system could get reimbursed for something or the patient could get coverage for something if the problem is an emergency—because there are rules like EMTALA, [the Emergency Medical Treatment and Active Labor Act,] there's emergency Medicaid that provides reimbursement for emergency situations or that gives people access to emergency medical care.

But let's say it's really a chronic problem that a patient has. This happens very commonly when a patient has kidney disorder, for example. The route to treatment would be transplant or dialysis.

And yet, as the patient is undocumented, they are very unlikely to have access to transplants and often don't have access to scheduled dialysis. So what you have to keep doing is admitting them as an emergency patient over and over and over again. And this causes a lot of ethical uncertainty and distress for people who care for this population because it doesn't look like a good way to manage the disease.

And sometimes the hospital might simply admit the patient. They'll say, 'OK we'll admit them into the hospital; they're sick, and then we'll just start the dialysis from here because we can't get them into the outpatient clinic.'

Sometimes this happens with psychiatric patients where you'd like to be able to admit the patient to a psychiatric bed but you don't have enough [beds]. So you look for a medical reason to at least get them into some safer setting.

People often talk about this with respect to, ironically, patient safety. Since the IOM's 1999 report, To Err is Human, drew attention to the problem of medical error in the US healthcare system, there was a big push to make healthcare safer. So what you started seeing was a lot more rules and lists that people should follow.

At the same time, there has been research on how many rules people can follow before they start selectively using rules, because it's just simply too many [rules] to keep in mind, or it's taking too much time.

Workers in healthcare systems are under tremendous time pressures to complete tasks, and keep moving, and complete rounds and clock out by a certain point, and so on. So when more rules are added in the name of patient safety it can, paradoxically, make safety less certain because you're putting people under pressure to reduce and condense those rules in some way.

That was one of the great lessons—and there's attention to this in the book—of Peter Pronovost's work on checklists [for preventing bloodstream infections from central venous catheters used in intensive care units]…What his great insight was, was not that you just handed the list back to people and say here follow them.

You had to completely remake the way people did work in the setting, so that if one person started skipping something, the other person would call them on it. You would ally them in that goal in preventing the infection.

[There's also concern] because people are getting very attached to this idea of checklists as magical solutions… that is just a recipe for setting up more workarounds of checklists. Because the checklist is actually the product of the agreement between the people in patient care to keep the patient safe. And then at the end of it, they say, how exactly does our work proceed?

In [Pronovost's] project, they had many different versions of checklists, but it really has to start with that behavior change, rather than imagining that the rules will change your behavior.

HLM: Are there workarounds that are OK? And which ones are definitely not OK?

Berlinger: That's a very important question, because few things in ethics are up or down. You're always asking for the context in ethics. [It] asks you to think right off the bat, to be a little provocative.

This thing you feel that you have to do to get your job done, to make these little improvisations all day long, is that the right thing to do? Because in healthcare, the right thing to do usually has to do with [the questions]: Is it the right thing to do for your patients? Is this safe? Is this effective?

An example of a workaround that would be appropriate is [when] the plan that you have does not fit the situation at hand in this particular case. So I give an example in the book of a patient whose needs for pain management have clearly changed, but there's no one on hand to actually give the order.

[Maybe] the hospital has a policy for written orders [but] there's no one on the floor who actually has the authority to write the order. So you would either have to do a verbal order, which would be preferable to someone who didn't have the adequate knowledge of the situation trying to just improvise. You don't want people who are less experienced or not authorized…to just wing it.

You might have to say, 'OK there are situations where our procedure cannot be followed for some particular reason.' But if that does arise, you would also say, 'Do we also have a staffing issue?' We don't want to put people on the floor in a bind when a patient is in pain, but they may not control their own staffing there, they're unlikely to do that in fact. So how does that go up the line?

You [also] often hear people talk about problems involving getting equipment fixed. Do you say to people, well you should make it work? Or do you say, we need a better system for figuring out how to get repaired equipment back up to the floor so that people aren't forced to use equipment that isn't working properly.

There might be a one-off circumstance [when a workaround is OK]. The problem is when it becomes a new norm, and you're adjusting or adapting to a situation that is more imperfect than it really needs to be.

More complicated ones, and ones that… get you into deeper waters, are when, for example, there's just a rejection of a new system, when you want to stick with the old one. And that can happen when you're putting in a new IT system or an electronic health record system.

The big bottom line is that behavior change is hard.

But if people are rejecting a system in such a way that they are figuring out how to work around it—there are whole presentations in the IT world about this, [on how to] defend your system from the inevitable workaround—sometimes what is needed is not just to punish people for doing that.

[Maybe you should] say, 'Wait a minute, are they actually sort of crowd-sourcing it? Is there a way that people could actually make it better?' And this could be an IT system, forms, other sorts of processes, but you have to be open to…doing quality improvement research your organization, taking that approach.

So that's definitely an issue for leadership: Are we allowing people to give us feedback about how our systems are working in ways that are not dismissed as complaints? Or that we're going to turn it back to this person [and say] 'you are being tasked with fixing the problem' when they've drawn a system-level problem to our attention.

How do we keep this responsive? If people feel as though if they speak up they're just going to be called a complainer, or [that they'll] be given some new responsibility, they'll just keep quiet about their workarounds. They'll just keep doing it their way.

That's always a little tipoff: If you are doing something but feel that you shouldn't tell anyone about it, that's a tip that it's on potentially ethically shaky ground. Secrecy goes with lying or concealment.

This is part one of a two-part interview.