Massimo di rienzo_17_06_2017

@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

@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»
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

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INTEGRITY BUREAU
• Integrity management team
• Prevention of corruption manager
• Focal-points
INTEGRITY PILLS
• Leaders
• Healthcare Department Chiefs
• Administrative managers
DISSEMINATE ETHICS
• Administrative personnel
DESIGN OF ISPE ETHICAL DILEMMA TRAINING

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Fraud, corruption and waste in healthcare are quite
peculiar…
…Take, for instance, the «information asymmetries»

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• 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

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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…

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but…
…let’s add some more complexity to the scenario»

@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

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• «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
…suppose we were in a training session…

@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?

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Marta is facing an ethical dilemma…
COMPETING VALUES OF PUBLIC ETHICS STRUGGLE…

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• 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)

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Code of Conduct)
• 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)

@spazioetico
Code of Conduct)
• 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

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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?

@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?

@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)

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“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)

@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

@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

@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

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• 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

@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

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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

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SPEAK-OUT
(BLOW-THE-WHISTLE)
IGNORE
…the most powerful ethical dilemma arises…
becoming aware of a potential corruptive conduct
what to do?

@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…

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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?

@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;

@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;

Massimo di rienzo_17_06_2017

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