Who Should be Seen as a "Healthcare Executive" and Why Does it Matter?

The American College of Healthcare Executives (ACHE) has as its vision "To be the premier professional society for healthcare executives dedicated to improving healthcare delivery." ACHE's excellent 2015 statement - Creating an Ethical Culture Within the Healthcare Organization - rests on an assertion I wholeheartedly support: namely, that "all healthcare executives have a professional obligation to create an ethical culture." (I added the emphasis)

If you agree with the ACHE assertion, and I'm prepared to go to the mat for it, the first question is: what counts as a "healthcare executive"? How wide is the scope of the term?

Clearly, executives at hospitals, medical groups, and other organizations that deal directly with patients carry major moral responsibilities. After all, health care is crucial for realizing all three of the "unalienable rights" put forward in the Declaration of Independence: life (sometimes health care saves our lives), liberty (we can't exercise our freedom without health), and pursuit of happiness (we can be happy without health, but it's more difficult, and severe enough pain makes it impossible).

ACHE deliberately leaves the scope of the term vague. It defines itself an an organization for "healthcare executives who lead hospitals, healthcare systems and other healthcare organizations." From my experience as a physician, administrator, and patient, I'd cast a wide net for defining "other healthcare organizations" and setting ethical expectations for them.

In the complex U.S. health system direct care organizations aren't the only important moral agents. Health plans and pharmaceutical companies are perhaps the two most important examples of indirect moral agents.

Over the years I've tried to encourage health plans to create ethics programs the way Harvard Pilgrim Health Care, where I have directed the ethics program for sixteen years, has done. I've had zero success. This doesn't mean that other health plans are unethical, but it does suggest that ethical performance is not seen as something that requires the kind of concerted leadership the ACHE statement on responsibility for creating an ethical culture calls for. (For a previous post about my quixotic efforts, see here.)

Executives in the pharmaceutical industry face especially difficult challenges in relation to the kinds of expectations the ACHE standards articulate. They're clearly crucial participants in  the sacred calling of health care. At the same time, they're embedded in a highly competitive industry with strong profit demands. Pharmaceutical executives work in the jaws of a severe dual agency challenge: sacred calling vs the invisible hand of the market.

More than forty years ago, Arnold Relman warned of the potentially disruptive moral impact of what he called "The New Medical-Industrial Complex." Since his prescient warning there have been efforts to establish a shared moral code for all participants in the world of health care. A distinguished U.S. and U.K. group articulated the "Tavistock Principles," but these, alas, seem to have been dead on arrival, and have not been heard from for fifteen years. And for a number of years the American Medical Association sponsored an "Ethical Force" program that sought to establish measurable ethical standards for the major players in the health sector. I had the privilege of being on the advisory panel on health benefits determination. The project produced some excellent materials and a book, but as with the Tavistock principles, the effort was relatively short-lived.

When I mulled over how to end this post I realized that I don't have a tidy upbeat ending. The image that came to mind was of Sisyphus, eternally pushing a rock up the hill. It seems to me that Arnold Relman's call to action points to an ongoing task captured in this cartoon:

I'll do more rock pushing in future posts!

Mindfulness, Clinical Outcomes, and Patient Safety

Two months ago, when I wrote a post about using the walking we clinicians do in the course of the working day as opportunities for  meditation, I wondered if it was a harebrained idea or a piece of personal eccentricity. But when I came upon "Use Hand Cleaning to Promote Mindfulness in Clinic" published in BMJ earlier this month, I decided there's something to it.

The author is Heather Gilmartin, a nurse fellow in the Colorado VA system. She makes the excellent suggestion that hand washing, a recurrent act of patient care and self care, can be used as a moment of meditation. Here's the practical summary Ms. Gilmartin presents:

A moment of mindfulness

Focus your attention on your thoughts and emotions. Stay present and accept whatever arises, just as it is, without reacting.

Set an intention—be it listening with intent, choosing your words mindfully, or acting with compassion in your next encounter.

Smile to acknowledge this act of kindness to yourself and to your patient.

Alcohol based hand rub

Pause, take a breath, and notice the sound and feel of hand rub being delivered to your palm.
Be present in the moment and experience the sensation of rubbing the foam/gel into your wrists, hands, and fingers until the product evaporates and leaves you clean.

Soap and water

Pause, take a breath, notice that you are turning on the faucet, and regard the feeling of water flowing from your wrists to your fingers.
Be present in the moment and experience the sensation of rubbing soap into your wrists, hands, and fingers, and then washing it all down the drain.

The VA system disseminates innovations well. I anticipate the potential for an epidemic of meditative moments arising from Ms. Gilmartin's modest but well articulated proposal!

Via her article I read an empirical study of the simple idea of using recurrent components of our days as opportunities for "mini-meditative-moments." College students were instructed to wash dishes in their usual manner or to do the ordinarily mindless chore in a mindful manner. The group that meditated as they scrubbed showed increased positive emotion and decreased "nervousness." (The article is at:
"Washing Dishes to Wash the Dishes: Brief Instruction in an Informal Mindfulness Practice.")

Reading the two articles emboldens me to out myself for another practice I've built into my day. I'm vigilant about brushing my teeth twice a day. If tooth brushing takes one minute, in a year it adds up to 12 hours. If it takes two minutes, it's a full day. That's a lot of time to devote to an uninspiring chore. I've taken to applying what Ms. Gilmartin recommends for hand washing to those moments of tooth brushing. It's an N of 1 experiment, but I believe it makes a contribution to overall well being.

I believe that most participants in the US health "system" would agree that the "system" is a mess. There's a massive outpouring of proposals for fixing the broken "system." We need to seek mega-solutions. But micro-improvements, such as what Ms. Gilmartin proposes in her BMJ article, are steps all of us in health care can and should take as part of the larger movement of creating an ever-more ethical environment of care.

The Four "As" of Ethics

Here's a mnemonic I've found useful for thinking about the actions health organizations need to take to walk the talk of their values:

1. Analysis ("what is the right thing to do?") This is the activity most familiar to ethics committees and classes in ethics. When is it right to pull the plug? At what age should children make their own health care decisions? When the term "ethicist" is used it's generally associated with the analytic activity.
2. Advocacy ("let's do the right thing!") This is the charismatic leadership function. When  leaders are seen as admirable exemplars of the organization's values, bureaucratic position and natural authority coincide. This is a uniquely powerful configuration. But every group has members who others respect and want to emulate. Wise leaders look to these widely admired member of the group as strong influences on the organization's ethical culture.
3. Administration ("we need to create structures that make it easier to do the right thing.") Ethical behavior is strongly influenced by internal ego ideals, but it's also shaped by external factors like prompts in an electronic record that help us conduct and record advance care planning and nudge us when it hasn't been done.
4. Accountability ("how well are we living our ideals? how can we improve?") Many years ago, a primary care colleague had his assistant ask every patient after their appointment - "did Dr. X do what you needed him to do today?" If the answer was "no," the assistant was trained to intervene, either directly or by calling in to the office. Now we have well developed systems like Press Ganey to assist with accountability at the population level, but the basic function is the one Dr. X implemented on his own.

Ethically admirable health organizations need to cultivate all four of the "As". 

Walking Meditation and Health Care Ethics

Health care can be frantic. Emergency rooms, intensive care units, and surgical suites are obviously high paced, but so is "ordinary" hospital and outpatient care. In my busy days of practice I sometimes had 18 appointments in 10 hours. It's not surprising that clinicians report high levels of tension.

Tension can sharpen our focus, but when it's sustained over time it can lead to irritability and distraction. These create hazards to patient safety and contribute to burnout. That kind of tension is bad.

Insofar as the conditions of practice can be modified to reduce tension, doing what's needed and possible should obviously be done. But clinical practice inevitably brings tension. For our own sake and for the sake of our patients, we need to develop ways to chill out. As the late Ken Schwartz wrote in "A Patient's Story," "...in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver’s inherent compassion and humanity." To be truly effective caretakers, we need to cherish our capacity for "compassion and humanity"!

For some, meditation is a tremendously valuable tool!

Unfortunately, meditation is often thought of as a touchy-feely matter of sitting in an uncomfortable lotus position and chanting mantras. That view confuses external practice with the internal objective. If meditation is taken to mean sitting in a quiet space for 20 minutes or more to carry out the practice, not many health professionals will make use of it.

That's where walking meditation comes in. In hospitals, doctors and nurses typically walk a few miles - in short bursts - during a shift. In my outpatient practice I often walked from my office to classrooms where I taught and to meetings at the nearby hospitals. I could even take a few paces in the office between appointments. I tried to use these interludes as opportunities for meditation.

There are excellent on line guides to walking meditation. (See here, here and here for examples.) But no approach fits everyone. I found that the excellent descriptions of how to focus on body sensation and the experience of walking didn't work for me. My mind kept wandering to matters I was fretting about. That got me riled up, not settled down.

I recently found a technique that works well for me. I like to look around as I walk. Here's what I learned to do:

1. Breathe in, and, at the same time focus my eyes on some aspect of the external world, as by saying "look at the trees," or "look at the clouds," or "look at the people."
2. As in all forms of meditation, the aim is to experience the trees, clouds, people passing by, or some other focus, not to think about them.
3. I found that for my obsessional nature, it helped to say numbers sequentially as I breathed out - one number for each cycle. That seems to help me stay with the experience rather than drifting off into ruminations. I also like to keep track of how long I can sustain the process before my mind gets filled with trivia.

I present my experience to make the point that it's kosher to develop an approach that works for us. Gurus can be helpful teachers, but the wise ones don't look for slavish followers. If walking meditation clicks for a person it can fit into the interstices of the day. Parents give children a "time out" for the child to regain some composure. Walking meditation has potential for potentially stressed out health professionals to create mini "time outs" for ourselves. When it works it serves us and our patients well! That's good ethics!

Hospital Ethics Committees

Hospital Ethics Committees, the most important organizational structure in health care ethics, are a decidedly mixed bag, as measured by skill, reputation, and utilization of the consultation process. Kevin O’Reilly’s excellent article in the current American Medical Association News provides a very full update.

Almost all hospitals with more than 200 beds offer ethics consultation. But the median use is approximately 3 consults per 100 beds per year. Anyone who has worked in a hospital and seen the conundrums that emerge so regularly knows that 3 per year is very low.

O’Reilly cites multiple articles and interviews for concluding that (a) consultants are often under prepared for their role, (b) physician attitudes towards the consultation process are often negative, and (c) evidence for the effectiveness of the consultation process is weak. Howard Brody, director of the University of Texas Medical Branch Institute for Medical Humanities, commented that "if ethics committees were a drug, they would not be approved."

For two reasons, however, I expect that in the next 5 – 10 years we will see an upturn for ethics committees and the consultation process.

First, systematic research on the consultation process, combined with quality improvement interventions, will lead to enhanced consultation techniques and outcome monitoring. The Veterans Affairs IntegratedEthics program, initiated in 2007, is an example of the kind of systematic development that is needed.

Second, the change of language in the 2004 Federal Sentencing Guidelines for Organizations from “compliance” to “compliance and ethics” combined with the statement that organizations should “promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law” creates a strong push for strengthening ethics activities.

Hospital ethics committees are at the end of their entrepreneurial phase. They are up and running and widely disseminated. The phase we are entering now is managerial. The primary challenge is getting more mileage from the time, energy, and (limited) dollars that have been invested in launching them.