Saturday, July 3, 2010

Beyond right and wrong

Beyond right and wrong there is a field.
I will meet you there. -Rumi

Dr. Jon Stanger ended his talk Thursday,"Beyond Right and Wrong: Six Parables for Medical Ethics" with this quote.

I can't help but reflect on Jon's talk and wonder about the implications of applying this thinking to the creation of a safe and just culture at CCRMC?

With the publication of the 2000 Institute of Medicine (IOM) report, "To Err is Human," patient safety and quality improvement have taken a prominent position in provider and public attention. There is now a prevailing acceptance that medical injury due to complications of treatment is occuring at an alarming rate. According to a 2009 publication by Lucian Leape, medical injury continues to affect approximately 10% of hospitalized patients, causing tens of thousands of preventable deaths each year.

Leape, commonly recognized as the father of the modern patient safety movement in the United States, calls for a departure from a culture of blame to a culture of safety. The organizing principle he says, is that the cause is not bad people, it is bad systems. It is further noted and supported by the work of many safety experts that to transform to a safe and just culture, we must engage in work in the following six areas:
1. We need to move from looking at errors as individual failures to realizing they are caused by system failures;
2. We must move from a punitive environment to a just culture;
3. We move from secrecy to transparency;
4. Care changes from being provider (doctors) centered to being patient-centered;
5. We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork;
6. Accountability is universal and reciprocal, not top-down.
Leape L.Errors in medicine. Clinica Chimica Acta,6 June 2009,404(1)2-5
To further complicate matters, systems for identifying and learning from patient safety events need to be improved. Safety reporting systems are often laborious and cumbersome. Health care providers express fear that findings may be used against them in court or harm their professional reputations. Many factors, such as concerns about sharing confidential data across facilities or State lines, limit the ability to aggregate data in sufficient numbers to rapidly identify important risks and hazards in the delivery of patient care. More work is also needed to develop measures that capture the underlying processes and conditions that lead to adverse events and the practices that are most effective in mitigating them.(AHRQ, NHQR 2009)

It can feel very complicated and even overwhelming at times. Yet I wonder if the highest walls we must climb are within ourselves? Although it's tempting to think fixing the individual pieces of our system is the way forward, we are not here to merely fix/optimize our current system. I have experienced many distractions along my journey but none more powerful than my own beliefs about what is possible, what I am capable of and what we are capable of. To settle is not an option. If we fall down seven times, we will get up eight. We are here to transform our system, to find the field. We are here to make a new world.



  1. I am very pleased to see that our CEO found my conference relevant on the level of systems development. I spent most of the hour discussing the value of expanding our vision of ethics in the realm of clinical practice. But the benefits of engaging a more diverse ethical perspective are also important to the emerging discipline of organizational ethics.

    Rules, principles, and policies are important. They offer some measure of protection against substandard care and demand adherence to basic requirements. But ethics should be about more than assuring a basic minimum - what one scholar has referred to as a "morality of the depths". Ethics should call us to fulfillment of our better selves, individually and as an organization. So, as we look to become an organization of excellence, we must demand more of ourselves than simple attention to rules and regulation.

    This requires that we meet in the field that lies "beyond right and wrong." In this field, rules and regulations are worthy of respect but are never sufficient in and of themselves. The path to excellence is not a fixed, concrete reality found in some atlas of health care organizations. Rather, it is laid one stone at a time - laid by you, and by me, and by us together in the course of our daily work.

    Success depends upon two key elements. First, the organizational mission must be part of the professional identity of every member of the organization. And, secondly, there must be an explicit commitment, starting at the highest levels of leadership, to open and respectful communication.

    Mainstream health care ethics in this country grew out of legitimate concern with stemming shocking abuses of human experimentation and medical paternalism. The result has been an ethical framework that emphasizes attention to principles and rules almost to the exclusion of other important moral perspectives. The call to patient safety and excellence of care requires a more demanding organizational ethics that draws upon a range of ethical theories that go by such names as virtue ethics, ethics of care, and discourse ethics. This view of ethics is complex and scary, but also empowering. The responsibility becomes ours, individually and collectively. It will require that we see the best in one another and that we be willing to meet in the field that lies out beyond right and wrong.

  2. Jon, I see why Anna was so exhilarated by the noon conference last Thursday. Thanks to both of you for bringing this discussion to those of us who could not be present.

    I love complex and scary conversations and pushing myself to a higher moral ground. The improvement work at CCRMC, the Healthcare Partnership, and the Ops meetings are often complicated and emotionally charged, but they are leading us beyond right and wrong. They have helped me look beyond my anger at the mental health system that has caused harm to my family.

    When I first entered the stakeholder discussions of the CCC mental health system, four years ago, there was such an entrenched sense of right and wrong, positive and negative, good and bad. There were stakeholder wars with no sign of peace. At one point, I thought that the only possible place to meet was within the basic realm of laws, regulations, rules, policies, and procedures. Surely there we could find agreement as to what was right. But, then there were all of those individual interpretations of those basic rules and regulations and those very human tendencies to defend ones own interpretation and the status quo.

    I was so convinced that I was right and that all I had to do was find a way to show others of their wrong thinking. Then my first Kaizen experience, a year ago, taught me to consider tolerance for those who don’t understand my experience. I was exposed to their experience, too. I recognized that nobody in the mental health system actually set out to make my family suffer. It was the system that harmed my family, not individuals doing their jobs. These individuals, who I thought were so wrong, were doing what they were trained was right, within a broken system.

    I have fallen down at least 7 times and I keep getting up because settling is not an option. I have dug deep within to find a core of values that will allow grace, respect, forgiveness, and the internal peace to stay the course of system transformation. When I have moments of shame and blame, based on years of unspeakable abuse and paternalistic medical speak, I have partners who remind me to consider a more respectful way to influence and to try a more ethical form of discourse.

    As a family member, I have appreciated helping CCRMC to build a path to the “…field that lies out beyond right and wrong.” I invite others to help us lay the next stone.