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Massimo di rienzo_17_06_2017

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AN ETHICS EDUCATION MODEL. Slides presented in "Open House EHFCN" Event – Rome (Italy) – 15th & 16th June 2017

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Massimo di rienzo_17_06_2017

  1. 1. @spazioetico EHFCN Open House 2017 Rome, June 15th 2017 Massimo Di Rienzo Scientific Director @ISPE Sanità Founder @spazioetico AN ETHICS EDUCATION MODEL The experience of «ethical dilemma training» in promoting integrity for italian public healthcare
  2. 2. @spazioetico STRENGHTS • Mandatory training • National Plan focuses on «real- life scenario» training WEAKNESSES • Low involvement of healthcare professionals • Compliance- oriented training OPPORTUNITIES • Healthcare professionals are used to work with «scenarios» or «case history» • Healthcare professionals ask for challanging training THREATS • Too many rules reduce people’s sense of responsibility (Katz- Navon 2005) • Too many rules compress the “ethical space” (@spazioetico (2014)) TRAINING INTEGRITY IN ITALIAN PUBLIC HEALTHCARE SYSTEM
  3. 3. @spazioetico INTEGRITY BUREAU • Integrity management team • Prevention of corruption manager • Focal-points INTEGRITY PILLS • Leaders • Healthcare Department Chiefs • Administrative managers DISSEMINATE ETHICS • Healthcare professionals • Administrative personnel DESIGN OF ISPE ETHICAL DILEMMA TRAINING
  4. 4. @spazioetico Fraud, corruption and waste in healthcare are quite peculiar… …Take, for instance, the «information asymmetries»
  5. 5. @spazioetico • Marta is a public healthcare professional who recently started working at the Department of General Surgery. • She’s responsible for the Department agenda. • Her work is in contact with users, who are, mostly, people in the unpleasant situation of having to undergo surgery Marta Francesca • Francesca is preparing for surgery. • Her surgeon has required a number of medical examinations to be done quickly and, in any case, before the surgery takes place. • One of such exam is particularly hard to carry out and Francesca, who is already used to this kind of analysis, confesses to Marta that she will probably not be able to find space in the public hospital. • She will have to go to a private clinic. REAL-LIFE SCENARIO
  6. 6. @spazioetico Marta Francesca • DO YOU KNOW ANY PRIVATE CLINIC WHERE I CAN GO? • I DON’T KNOW ANY … YOU SHOULD KNOW BETTER… • MMMMMMHHHHH…. REAL-LIFE SCENARIO …here you can see «information asymmetries» in action… …healthcare professionals are supposed to know more and better than the patients, …and, in general, it is a good thing…
  7. 7. @spazioetico but… …let’s add some more complexity to the scenario»
  8. 8. @spazioetico Marta FrancescaDoctor Wolf • Doctor Wolf, who is a General Surgery’s specialized doctor, approaches Marta… • “I’ve got a clinic just right for your patient”, says to Marta. • “The owner has assured me that operators are able to provide low cost service in a very short time”. • “Just give her this business card”. • Marta starts thinking that she could give Francesca a very good advice, delivering one of those business cards. DO YOU THINK SHE’LL DO THE RIGHT THING? BRINGING COMPLEXITY TO THE SCENARIO
  9. 9. @spazioetico • «No, no, no, this can’t be done. It’s not an appropriate conduct by a public officer…» • «I don’t think there’s any problem with this conduct….» Marta FrancescaDoctor Wolf BRINGING COMPLEXITY TO THE SCENARIO …suppose we were in a training session…
  10. 10. @spazioetico GUIDING QUESTIONS • How do information asymmetries work in this case? • How do power asymmetries work in this case • How do conflict of interests work in this case? and • How do «competing principles or values» of public ethics struggle to determine what is right and what is wrong? BRINGING COMPLEXITY TO THE SCENARIO
  11. 11. @spazioetico Marta is facing an ethical dilemma… COMPETING VALUES OF PUBLIC ETHICS STRUGGLE…
  12. 12. @spazioetico • On one side, «giving good advice» adheres to a public officer’s mandate, which is, taking charge of users. (art. 12, comma 1, National Public Officers’ Code of Conduct) Marta is facing an ethical dilemma… COMPETING VALUES OF PUBLIC ETHICS STRUGGLE…
  13. 13. @spazioetico • On one side, «giving good advice» adheres to a public officer’s mandate, which is, taking charge of users. (art. 12, comma 1, National Public Officers’ Code of Conduct) Marta is facing an ethical dilemma… COMPETING VALUES OF PUBLIC ETHICS STRUGGLE… • On the other side, she can just inform users with different services available. Otherwise she might modify competitiveness conditions of private clinic market and set off an «adverse selection». (art. 12, comma 3, National Public Officers’ Code of Conduct)
  14. 14. @spazioetico • On one side, «giving good advice» adheres to a public officer’s mandate, which is, taking charge of users. (art. 12, comma 1, National Public Officers’ Code of Conduct) Marta is facing an ethical dilemma… • On the other side, she can just inform users with different services available. Otherwise she might modify competitiveness conditions of private clinic market and set off an «adverse selection». (art. 12, comma 3, National Public Officers’ Code of Conduct) EFFECTIVE ACTION IMPARTIALITY COMPETING VALUES OF PUBLIC ETHICS STRUGGLE…
  15. 15. @spazioetico ADVERSE SELECTION • Adverse selection is a concept in economics, insurance, and risk management, which describes a situation where market participation is affected by asymmetric information. ...what does «adverse selection» mean?
  16. 16. @spazioetico A PUBLIC AGENT • …a public healthcare professional working at the Department of General Surgery… MODIFIES COMPETITIVENESS OF PART OF THE PRIVATE LOCAL SECTOR • …to determine an advantage of a competitor or group of competitors (to whom she may herself belong or not)… CAUSING A SELECTION OF COMPETITORS • …some of which will be in a position of advantage over others… UNFAVORABLE FOR THE PUBLIC • …as only competitors who are willing to violate the rules will stand …what does «adverse selection» mean?
  17. 17. @spazioetico An ethical dilemma can be described as a decision that requires a choice among competing sets of principles, often in complex and value laden contexts. Kidder (1995)
  18. 18. @spazioetico “Organizations often have ‘‘competing value systems’’ from which dilemmas arise. Such dilemmas cause an ethics struggle when it is unclear as to what the ethical thing is to do. Muel Kaptein The Battle for Business Ethics: A Struggle Theory (2015)
  19. 19. @spazioetico National Public Officers’ Code of Conduct Public employee Codes of conduct of the medical professions. Doctors Veterinaries Nurses … Codes of Conduct of providers’ system Pharmaceutical Devices Research … ...this is particularly true in the public healthcare system, where we have a GALAXY of different value systems …often competing… • QUALITY • GAIN • IMPARTIALITY • EFFECTIVENESS • BEST POSSIBLE TREATMENT/ CARE
  20. 20. @spazioetico • Here’s Mr. Rossi, an accountant who works in the procurement office of a public hospital. • While preparing technical specifications for a call for tender, he accidentally bumps into some anomalies. COMPETING VALUE SYSTEMS IN PUBLIC HEALTHCARE AND HOW ETHICAL DILEMMAS ARISE 2. «SPEAK-OUT DILEMMA» REAL-LIFE SCENARIO
  21. 21. @spazioetico • He notices that there are three different purchases. • In the first, the hospital has already bought a "medical device", that is, the basic machinery, without any other element which is necessary to make it work, such as an appropriate software or maintenance service. • Normally, you do not buy a device without software, because it means that you will need to prepare new documents for new purchases. A great waste of time. • That is the first anomaly. purchase #1 medical device
  22. 22. @spazioetico • A few days later, Mr. Rossi notes that there are, actually, two more purchases. • In this case, the hospital intends to buy a software and the maintenance service of a generic medical device. • Both the software and maintenance service, after a quick analysis, result compatible with the medical device previously purchased by the hospital. • This is the second anomaly. purchase #2 software purchase #3 maintenance
  23. 23. @spazioetico • Suspicion grows after Mr. Rossi notes that the procurement procedure is, for all three purchases, the “direct award”. • That means no public tendering for the three purchases. • And this is the third anomaly. • There is something wrong here. • What to do? DIRECT AWARD instead of PUBLIC TENDERING
  24. 24. @spazioetico POTENTIAL FRAUD Artificial division of one supply into a number of lots, in order to divide costs, go subthreshold, thus, avoid public tendering and circumvent legislation on public procurement POTENTIAL CORRUPTION The public official in charge of the purchases, may have requested undue advantage for himself or for a third person, in order to refrain from acting in the exercise of his official functions
  25. 25. @spazioetico SPEAK-OUT (BLOW-THE-WHISTLE) IGNORE …the most powerful ethical dilemma arises… becoming aware of a potential corruptive conduct what to do?
  26. 26. @spazioetico ...sometimes that conduct has nothing to do with FRAUD… ..IN PUBLIC HEALTH-CARE OFTEN DYNAMIC IS SOMETHING LIKE… …health-care professionals are those who «HAVE TO DO THE RIGHT THING», because they work in the front line. They have to be EFFECTIVE, fast, they have to provide best care to demanding patients… …administration officers are those who «DO THE THINGS RIGHT», as they have to be compliant to procedures. They have to be IMPARTIAL, and it takes time, a lot of time…
  27. 27. @spazioetico A NEW DILEMMA ARISES I need to buy a new device. The one I’ve got is out of date Ok. How much does it cost? Don’t know exactly, but lot more than the old one I’m afraid we can’t just buy it. We’ve to go through public tendering How soon do you need it? Yesterday . No, seriously, as soon as we can And how much time for that? Six months, maybe? You must be kidding me? For that time my patients will all be dead! …so, what to do?
  28. 28. @spazioetico Recommendation of the Council on Public Integrity (2017) 8. Provide sufficient information, training, guidance and timely advice for public officials to apply public integrity standards in the workplace, in particular through: … b) offering induction and on-the-job integrity training to public officials throughout their careers in order to raise awareness and develop essential skills for the analysis of ethical dilemmas, and to make public integrity standards applicable and meaningful in their own personal contexts;
  29. 29. @spazioetico Recommendation of the Council on Public Integrity (2017) Support an open organisational culture within the public sector responsive to integrity concerns, in particular through: a) encouraging an open culture where ethical dilemmas, public integrity concerns, and errors can be discussed freely, and, where appropriate, with employee representatives, and where leadership is responsive and committed to providing timely advice and resolving relevant issues;

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