Workarounds in Hospitals Raise Ethical Questions

Alexandra Wilson Pecci, January 25, 2016

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.


Nancy Berlinger, PhD

"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.

Q&A: Donald Berwick Calls for 'Moral' Approach to Healthcare

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.

Alexandra Wilson Pecci

Alexandra Wilson Pecci is an editor for HealthLeaders Media.


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