What Hospital Leaders Don't Know About Clinical Workarounds

Workarounds are inevitable in complex systems. When there is a disconnect between a system's rigid rules and what its workers feel they must do, leaders should give workers an opportunity to talk about the challenges they face, says a research scholar.

This is part two of a two-part interview.

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 shortcuts, system fixes, and rule-bending in healthcare.

Whatever you call them, she says, workarounds are decisions made, usually quickly and under pressure, "where the situation at hand does not fit the official rules for what you are supposed to do."

In part one of a discussion with HealthLeaders Media, Berlinger detailed the ethical questions that arise from the use of workarounds. In part two, she talks about bringing workarounds out of hiding, using them for good, and encouraging innovation in the workplace. The transcript of the interview has been lightly edited.

HealthLeaders Media: It seems like workarounds should be brought to light, and that systems should be open enough for interpretation so that everyone can work together on a problem, rather than having to adhere to a rigid set of rules.

Berlinger: That's a very good way of putting it. It's not to say that everything's up for grabs. We want to take critical thinking seriously. Are we giving people opportunities to comment on whether or not something's worked so we can improve it and then put it into practice as a good set of work rules? Mindful of the fact that healthcare systems are always changing, we're going to have to look at rules every so often.

Workarounds in Hospitals Raise Ethical Questions

I'm on a hospital ethics committee, and I remember years ago that there was a particular resource allocation decision that was happening in a particular unit, and no approach to it was working in a very satisfactory way.

Finally, they came up with a set of rules that might be acceptable, but one of the doctors said, 'Now we have to let the nurses put that into practice, because ultimately, if they reject this it's not going to work. If they feel that there's something wrong with this, or it's unfair, or it puts them into an odd situation, it's just going to be put to one side.'

It was taking a critical look, rather than simply imposing rules on people.

Hospitals are very complex environments, and medical practices are very complex environments, and it can be hard to prioritize what… things we're going to focus on.

If people feel as though their system is letting them down… You always know that when you're in that [kind of] organization versus an organization where people can say, 'This is a very challenging job, but I feel that the organization has my back and I feel that they listen to people.'

People can tell you that about their workplace, or they can tell you when they're feeling a sense of uncertainly in times of system-level change, if there's a merger going on [for instance].

[Employees might think] they don't know what the values of the organization are going to be from now on because there are new people in charge. So people need the opportunity to communicate during those times as well.

HLM: And people want to make sure that they're not punished for speaking up.

Berlinger: Oh, absolutely. That's incredibly important. Because there are so many ways that one could be well-meaning and say, 'We want to set up a way to talk.' But if people feel as though this is a one-way conversation, or it's really just a way to… lay down the law, or they're going to be viewed as complainers… [it won't work].

Because of the emphasis on consumer satisfaction, healthcare workers—doctors and nurses on the floor—are very motivated to avoid complaints, and they do not necessarily want to be viewed as complainers either.

They would, I think, like to be viewed as sources of constructive information about how work is actually proceeding and the needs of the patient population. But setting that up has to be done in a very thoughtful way so it doesn't trigger the idea that this is just a flavor-of-the-month, or they just want to figure out how they can make us do more work.

Know that even if you're going out with the best intentions, people may have had a bad prior experience, either in this organization or in a previous job. So approaching that very thoughtfully is important.

HLM: I know this is a very slippery area and that black and white aren't the colors of ethics, but what are some times when workarounds are definitely unethical?

Berlinger: The difficulty is when something is clearly unsafe for patients. That's the bottom line in healthcare.

HLM: The one that's jumping out to me is antibiotic stewardship. Where clinicians feel like they know what's best for their patients, but the hospital is trying to crack down on antibiotic overuse.

Berlinger: This is a good example because antibiotic misuse is a huge problem in this country and other countries. And also, patients and families and doctors have gotten used to antibiotics. And there can be powerful norms on both sides to say, 'Well, the thing that you're going to do is give me an antibiotic, right?'…So clinicians and organizations have to be very clear about…the ultimate goal of keeping an effective drug effective and keeping patients and populations safe so that you can use antibiotics when they're needed.

But it also requires sometimes saying no when someone would prefer you to say yes, or sometimes taking the time for an explanation when it would be so much faster to just write a prescription.

That's a very good example because it shows how that individual—that doctor, that nurse practitioner, that PA—has to be supported by the organization in order to do the safe thing. Otherwise it is very easy just to default to the thing that will keep things moving.

HLM: Can we talk a little bit about nurse "makers" and nurse "hackers?" There was one who was honored at the White House for doing these kinds of creative workarounds for patients. What are some of the ethical concerns around that?

Berlinger: One thing I've heard from a nurse, that I thought made perfect sense, was that a workaround is often the first draft of an innovation.

Every innovation starts with a workaround. You're seeing a situation where the rule, the tool, doesn't match the situation at hand. And if you actually follow the plan rather than the reality in front of you, you could actually wind up doing something very unsafe.

Surgeons can give the example of having a surgical plan but the patient has some sort of anomaly that the surgeon didn't know about… and the plan had to be adjusted on the spot.

What you would want to do in that situation is… share the results of what you did and the outcomes of it. So take a critical approach to it rather than just keep doing this new practice and never telling anyone about it…

So if the nurse hacker is being honored at the White House, it didn't stay at the level of a secret workaround or a semiofficial practice. [It's not] something you maybe told your colleagues about, but didn't tell your supervisor about. So at some point, this nurse must have decided to put this up for a kind of a [quality improvement] QI project, a QI investigation.

Organizations sometimes do have a sort of internal QI mechanism where you can study a different way of doing something. It doesn't mean that you're doing a full-scale research project, but you may say, 'We've come up with something better. We've observed something in our setting, and this would seem to make more sense.'

HLM: It sounds like workarounds need to come out of the closet in order to truly turn into something useful.

Berlinger: That's a good way of putting it because they're an inevitable feature of work in complex systems…which should be differentiated from just saying that healthcare is complicated.

Complex systems are systems that are so big they're not under the control of a single decision maker. Work in the system has to proceed according to rules and protocols, and smaller systems—like IT for example, like medical records—to guide them. Complex systems are always changing.

In healthcare, there are new people coming in the door constantly through the emergency room. And work is always adapting to change. So in situations where work is always adapting, workers are going to be very sensitive to situations where the rules that are supposed to govern work and the actual conditions of work don't match up.

There's constant pressure. And adding to that are the economics of the healthcare system. When you're under constant productivity pressure, it drives these workarounds. Complex systems also have the potential for harm, because they run, often, 24/7.

They can't be shut down to fix problems… it never works that way in a hospital. So workers in these systems face pressures that others may not. And of course their mission is to care for the sick. So they're dealing with an exquisitely vulnerable group of people as those in their care.

It's talking openly about workarounds, asking people to share this in a non-punitive way, while at the same time taking a critical attitude—not criticism—taking a critical look at workarounds and saying which ones are actual first drafts of innovations? Which actually make a system better, and should be more widely shared, not just kept as my personal practice? [Is this] something that could actually be adapted by others?

[It's also important to ask] which ones are problematic and potentially harmful. Their value is unclear and why do people use them anyway? It's almost always because they feel that it saves time.

HLM: So some workarounds exists, not just to do something better for the patient, or solve a moral problem, but to save time.

Berlinger: Very, very often it's about saving time. Someone might think of it in moral terms by saying, 'If I get behind I can't see all of my patients, so I'm going to have to save time here on this case, and this case, and this case, and by the end of the day I have seen everyone.'

Versus, 'If I take all the time this is meant to take, there are people who aren't going to get their meds on time.'

There are these very quick moral calculations that people are making, but they are not all definitely in the interest of making things better for a particular patient—although sometimes they are.

Sometimes they're just simply about, 'How do I get my work done?'

Sometimes these are called 'efficiency-thoroughness tradeoffs.' In systems like healthcare, people tend to get the message that they have to prioritize being efficient over being thorough. At the same time, they're always told that they must be very thorough.

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

HLM: What would you want C-suite executives to take away from your book?

Berlinger: In the last chapter of my book, most of the recommendations are addressed to leadership because…even when you're describing a front-line problem, it always has something to do with leadership in some way. Leaders set the tone for the environment.

First, the C-suite has to acknowledge the complexity of the healthcare environment and acknowledge how important they, themselves, are in setting the tone for what workers will perceive as important or unimportant to the system itself.

All healthcare organizations describe themselves as committed to excellence and to caring. You see that on the website; you see that on the marketing materials, and so on. But if front line workers are demoralized and don't perceive that they have the time or the tools to provide excellent care, those are always leadership concerns and maybe are the result of system-level decisions.

Leaders should acknowledge the foreseeable challenges facing workers in their systems. For example, in systems that rely heavily on Medicare reimbursement, like hospitals, it's foreseeable that many patients will be older, will be experiencing age-associated health problems, and will be facing decisions associated with the last stage of life, because they're on Medicare and they're in the hospital.

In a safety net system, which relies on Medicaid reimbursements and other funds, it's foreseeable that many patients will be uninsured… and workers will face resource allocation challenges regularly.

We have to be upfront about these things because this is what your workforce is seeing. If there's a disconnect between what the C-suite is talking about and what the workers are seeing, it's just a recipe for your workers to be demoralized or some of your workforce to want to leave, or for care to be not as excellent as it might be.

I think one thing we should always be careful about in healthcare is expecting some people to be heroes. The idea of being the person who's going to be the savior of the system…this is obviously a collective enterprise…we ought to give everyone an opportunity to be good at what they do.

As we discussed, leaders need to give workers an opportunity to talk about the challenges they face without [creating a] complaint session or an opportunity to task people to solve problems that are way above their pay grade or their level of responsibility.

They should support QI problems in their own settings… How do we bring workarounds out of the closet? [You do that] by encouraging people to talk about their innovations and say, 'OK. Now let's see whether some of these could have broader applications.'

Also, [let's] help people think critically about situations where they felt pressure to improvise in ways that were not putting patients' interests at first. Not that they meant to do that, but they felt pushed to do that.

Sometimes they are not only about the individual doctor or nurse. These are maybe situations where the rules of admission, for example, of a critical care unit are unclear. So there's a habit of referring a lot of patients to a particular unit just in the interest of their safety.

But then the people who actually work in the unit have way more patients than seems safe to them. So there's a little workaround there: We'll find a reason to get [the patient] in there, and it'll be OK, but we haven't really thought of our colleagues on the other side of the door who are managing the problem…

Sometimes it means looking back at the unglamorous things like staffing ratios: How many patients with this particular condition is it reasonable to imagine one person to take care of safely? That kind of stuff can drive workarounds. It can also be the difference between safer and less-safe conditions.

I think attention during periods of system change is very important because system change introduces new pressures….

One final thought is [that] I think both the C-suite and front line clinicians themselves always have to be thinking about who they view as deserving or difficult or demanding, because that goes to the level of moral intuition.

This is true with respect to the patient population and… with respect to their own workforce. Who are we listening to, and who do we think we should do more for because we think they deserve things? This may be a patient who we like, or a particular unit that produces a lot of reimbursements.

Who do we view as demanding? Is it a particular kind of patient, or a particular profession? But we always have to be alert to that in any kind of work because, as the social psychologists can tell us, it tends to guide what we actually do.

If there's a problem you don't want to deal with—and in healthcare the problem can present itself in the form of a patient—you might want to "turf it," which is physician slang for get rid of it, get it off my turf and onto somebody else's turf.

You may find a way to get rid of that problem by pushing it somewhere else, and just making it someone else's problem. You see it in end-of-life care; you see it in psychiatric care. [These are] situations where patients are just turfed between institutions or turfed between units…

Analyzing these problems is tough. And figuring out how, in organizations that are very busy, you can prioritize problems you're going to work on is challenging. So I'm always interested in how… leaders talk among themselves in their own C-suite. Where do leader learn from? How do different professions talk within their own professions? How are we talking about this?

Not just in economic language, but in moral language. Because healthcare ought to be a moral enterprise, it ought to be a good-seeking enterprise. It's about the care of the sick, and the healing of disease, and the relief of suffering. But it's all of our actions and inactions that actually show whether it is a moral enterprise.

This is part two of a two-part interview.