A Case of Bad Ethics: There’s No “I” in Team, But Who Cares?
When collaboration is stymied by self-interest
Collaboration offers many benefits but inevitably entails give and take. Individuals must be willing to give up some of their autonomy in order to pursue outcomes that benefit the greater community. Refusal to make any concessions means that the collaboration can be easily derailed by what might otherwise appear to be minor obstacles. Identifying and articulating these non-negotiables from the outset may prevent impediments that limit the possibility of success.
Administrators at three small local hospitals realized that the demand for mental health services outpaced the current availability at each of their institutions; they decided to work together to enhance their offerings. Not only were more patients coming to each hospital for help; because the patients’ specific needs varied, the practitioners at each hospital felt that they needed to be a “jack of all trades” for mental health—experts in every area. Administrators recognized that it would not be financially feasible to hire practitioners for each of the separate mental health departments. By pooling their resources and creating specific foci for each department (e.g. one department would focus on issues pertaining to adolescents, another on depressive disorders, etc.), they could meet the patients’ needs and fill in gaps across the board.
Surveys of administrators and practitioners at each hospital confirmed overwhelming interest in this plan. The administration quickly made arrangements to open access to patients from the other hospitals and to arrange transportation between them. However, after the first billing cycle, administrators encountered a challenge they had not anticipated—variations in payment.
In fact, practitioners at the various hospitals were paid varying amounts. Moreover, patients’ payments for services also varied depending on insurance accepted at each hospital (if the patients even had insurance). Because one of the hospitals in a higher income neighborhood could afford to be more selective about insurance, patients who visited from poorer areas with more stipulations on their insurance were forced to pay “out of pocket” for services rendered. Furthermore, the hospital that focused on adolescent mental health issues became much busier, and although they wanted to help, the practitioners were beginning to squawk about having to work more hours, with no increase in salary. These practitioners felt they could not keep up the pace and petitioned to end the collaboration. More patients might be getting care, but it came at the expense of the practitioners, who now felt overworked and undercompensated.
Administrators across the hospitals organized a meeting to negotiate a solution. Everyone agreed at the outset that they could not lose sight of the interests of the patients or the original purpose of joining the departments across the three hospitals. After hours of heated discussion, a decision could not be reached. Administrators from each hospital had their own “non-negotiable” items, such as practitioners’ maximum work hours, their travel time, and types of “acceptable” insurance. Individuals around the table tried to strategize how to accommodate these items, but every suggestion was turned down for one reason or another. One hospital, for example, offered to exchange money to pay practitioners a “bonus” if those individuals worked more than the forty hours. Another hospital would not accept this—its reputation as “one of the 10 best institutions at which to work in the state” was not to be compromised. One of the hospitals agreed to see 20 patients a month for no charge (if they came with no insurance), but the other two hospitals asked, “What happens to the 21st patient? How do you turn down that person in need?”
As the meeting time extended beyond four hours, tensions mounted. During the breaks, administrators learned of practitioners’ concerns through emails and voicemails. Administrators became wary of negative press in the local newspapers. Knowing the importance of reputation at these local hospitals, the administrators unanimously agreed to put the collaboration on hold for the time being. They figured that because the collaboration had only been in place for a week, “little damage was done” in terms of public relations in the community. Ironically, the “big damage,” which no one considered at the time of the decision, was the patients in need.
Who suffers the consequences of this decision? Certainly, it seems that refusal to collaborate resulted in a deficit of necessary medical care for the patients who need and cannot receive timely services. In order to “save face,” administrators neglected to consider the people in the community who depend on them. Rather than being able to schedule an appointment within days, patients who face mental health problems would need to wait at least a month. Because none of the three hospitals was willing to concede on any of the items that might have yielded a potential solution, the collaboration became an example of how flawed “bad ethics” can undermine a needed solution.
These institutions all saw the benefits of collaborating, but the nuts and bolts of making that happen proved to be an insurmountable obstacle. Each hospital had its own payment structure that was dictated by requirements administrators felt they could not change. Unable to compromise on these issues, they could not create a collaboration that effectively served the patients in all of the hospitals. Each member of the collaboration acted in ways that would only serve a single hospital, not the larger surrounding community.