Introduction
The Nevada Research Hospital was founded in 1991 to be a research center aimed primarily at developing and testing new cancer drugs and treatment regimes. The hospital is housed in the Neovida Center, in Memphis Tennessee; and its establishment was funded by the New-Life Fund set up a decade earlier by private philanthropists for cancer research. The hospital started as a small facility housed in a single building and with an entire staff comprising of twenty people only. The center continued to grow in both size and stature; influenced both by increased funding and better articulation of the research agenda.
Today, the hospital has a workforce of over 1,500 employees; and the annual budget for the fiscal year 2008 was over $140 million. The focus of the center is research into the various aspects of cancer; including the causes, pathology, and possible means of treatment (See Appendix 1). This research is carried out in the facility’s laboratories and by the senior scientists (including physicians) who are permanently based there. Additionally, the center hosts researchers from other institutions who take advantage of the technical and human resources available; and who are adequately funded and have research agendas congruent to the center.
The hospital has a capacity of over 300 beds, devoted entirely to the treatment and care of cancer patients. However, the hospital also has an emergency department to cater for the acute care cases that may arise in the surrounding community; this however only serves adequately insured patients.
On average, the hospital admits over 3,000 patients every year; and approximately 30,000 patients are treated on an outpatient basis during the same period. Over the years, the center has been recognized for its major contributions to the knowledge of various neoplastic conditions; and other medical conditions and has received numerous awards for the same.
The day-to-day activities are administered by the Hospital Management Board (HMB) whose members are drawn from heads of the various departments; and are chaired by one of the members, the Executive Director (ED), elected on an annual basis. The ED reports and is a member of the Board of Trustees. The latter is made up of appointees from the various endowment funds and honorary members from the academic and medical fraternity, and functions mainly to set the research agenda for the hospital. The board also vets the appointments of senior researchers. The board is chaired by the New-Life Fund representative; whose appointment is left to the fund’s discretion and who serves as the Hospital President.
Problem statement
There is a problem in the relationship between the Hospital Management Board and the Board of Trustees vis-Ã -vis both the selection of the research partners and the usurping of the HMB power by members of the BOT.
The Problem
Recently, a problem has arisen over the testing of an experimental drug on 200 cancer patients. Many of those who enrolled in the program from 2006 were severely ill, and most had died by late 2008. In addition, results from earlier tests by another institution showed that the drug had lower efficacy than earlier suggested; and that treatment with the drug offered little or no hope for patients with advanced stages of cancer, the main target for its development.
The main point of conflict, however, was the revelation that the then (and current) president, James Smith, had extensive financial interests in the firm which developed the drug (and collaborated with the hospital to carry out clinical tests); and stood to earn millions of dollars if the tests had been successful. Additionally, the patients who were enrolling in the program were not fully informed of these interests; which would probably have influenced their decision whether to enroll or not. Finally, questions are being raised whether the allocation of the hospital’s (limited) resources would have been influenced by the president’s financial interests; and to the disadvantage of both the progression of research and the patients who enrolled for tests of an ineffective drug and subsequently died.
The conflict
Every year, the hospital’s Board of Trustees analyzes and selects from hundreds of requests from pharmaceutical companies, academic institutions, and individual researchers to collaborate in the clinical tests for the anti-cancer drugs that these parties have developed/discovered. The decision to choose one drug over the other is ideally supposed to be based on aspects of efficacy, medical ethics, level of development; and socioeconomic considerations.
As such, the chosen drugs are the ones shown to carry the best benefits for the patients, society, and the progression of cancer research. This effectively means that such a decision cannot be comprised entirely of medical professionals and/or academics, and explains the diverse composition of the board.
However, conflicts have arisen regarding the objectivity of the board, and in particular, the influence of the president in the choice of the drug to test. The management board in particular (which is largely a medical-professional team) has raised concerns over the choice of a candidate drug over other potential drugs vying for selection. Individuals within the management have voiced sentiments to the effect that the final selection should be the prerogative of the HMB rather than the board of trustees.
Such has been exacerbated by the fact that massive disproportionate resources were allocated to the testing of the drug. Including the building of a new, state-of-the-art laboratory dedicated to the program; all on the hospital’s tab. Additionally, the program had a dedicated team that reported (through its team leader, Dr. Jones) directly to the president, rather than to the management board; thus bypassing the facility’s ‘chain-of-command’; this has fostered resentment not-only from other members of staff, but also the management.
The issue of medical ethics has also been raised. While the medication has not been shown to cause any harm to humans, it has failed to achieve the efficacy levels originally aimed at. As such, most of the patients who enrolled in the program died for their respective neoplastic conditions. It therefore would have been better to fully disclose the financial stake of the hospital president in the drug to the potential enrollees; such would have given this patient enough information to make an appropriate choice whether to join or not or to enroll in other programs. However, whether this factor could have determined the outcome of their condition is a matter of speculation.
Summary of findings
- The patient enrolled in the clinical trials were not fully informed of the financial interest of the center’s president in the success of the trials; this antagonized the HMB, whose members are medical professionals bound by ethical obligations that require them to provide their experimental patients with the relevant information as would enable them to make a sufficiently informed decision (Curtis, 1997).
- The team working on the trial medication was allowed to bypass the authority of the HMB by reporting directly to the hospital president and was given preferential treatment in regards to resource allocation in form of a new dedicated laboratory.
- The president’s interest may have compromised objectivity in the selection of the medication as a candidate drug; this is in contradiction to the hospital’s aim of allocating financial, human, and academic resources to candidate drugs that have the best potential for cancer therapy.
Attempts at conflict resolution
Various interventions have been tried, aimed at solving the impasse between the HMB and the BOT. The main approach, however, seems to be trial and error measures that have not been appropriately targeted at the source of the conflict. Among some of these measures has been the reassignment of research support staff such as general physicians, specialty nurses, and interns to various research groups in form of a reshuffle. This move, initiated by the BOT was aimed at fostering unity within the hospital’s workforce and reducing the formation of factions within it. This move has however hurt the progress of research agendas; as members introduced to a new group have had to be given adequate time to realign themselves with the procedures, materials, and targets of the new group.
Additionally, this move has only served to circumnavigate the real problem, that the BOT has overstepped its boundary thus putting it in direct conflict with the HMB. Apart from the reshuffle, no other form of reform has been initiated by either of the parties. The prevailing impasse stands to cause major problems for the hospital. Indeed, some of the senior staff working in the Dr. Jones group; and who were neither aware of the procedures used to select the drug nor the financial interest of the president in the research outcome have started to contemplate removing themselves from the group in fear of losing morale and academic credibility.
Additionally, some of the crucial support staff such as specialty nurses have cited difficulties in working in a hostile and tense environment; and two very experienced nurses have already been spirited away by other prestigious cancer research centers. The center cannot afford to lose such experienced staff; this would have a devastating effect on the progress of research agendas, and the cost involved in replacing such staff is ghastly. Trial-and-error techniques will therefore only serve to undermine the center’s privileged prestigious ranking and inhibit the achievement of the mission of the hospital.
Recommendations
The key to resolving the current conflict is the creation of suitable organizational structures through which the selection of candidate drugs is done. A good measure would be to set standards through which a candidate drug has to attain first before being forwarded for consideration. Indeed, the potential efficacy of the drug should be of foremost concern to ensure that only drugs with good potential are chosen. If such standards would have been there in the past, the conflict would not have arisen in the first place.
Organizational restructuring should also ensure that measures are put in place requiring full disclosure of any individual interest by any person playing any part in the selection and testing of drugs. Such would be aimed at improving objectivity during these processes. Among the most urgent is to instill and pursue a policy of full disclosure of such interests to potential enrollees of any program; the credibility of the center is already at stake and lack of any action on the current situation would surely deny the center willing candidates in the future.
Secondly, the ‘chain-of-command’ in the hospital has to be re-instituted; all teams working on any project within the institution should report to the management board and not to the board of trustees or any of the latter’s members. Such would ensure trust and equality among all levels of operations of the hospital (Skjørshammer, 2001; Harolds & Wood, 2006). This would also require the opening up of proper and effective communication channels between various tiers; as such, no particular group would be inclined to skip any level of administration in –order to effectively communicate. Indeed, such channels would forestall a potential exodus of highly skilled and experienced staff from the center since all grievances will be heard and catered for (O’Mara, 1999).
Finally, there has to be a re-evaluation of the hospital’s mission; indeed, a lot of soul-searching is required and particularly on the highest level of administration, the Board of Trustees. To achieve the goals of the center and to retain its stature as a leading center for cancer treatment research, the board must be seen to retain maximum objectivity during the selection of partners; and each member must declare his/her interests in this selection so that they don’t overshadow the hospital’s work (See Appendix 3 for analysis).
Outcome measures
It is prudent to monitor the progress of the implementation process to ensure that the process does not fall short or get derailed during the one year. By the end of the process, there should be a real and perceived objectivity in the way selection of research partners; such would reduce the discontent among medical and research professionals working within the various research groups in the center (Skjørshammer, 2001; Mrayyan et al, 2008). Additionally, a proper and rigid administrative hierarchy should be in place so that some groups are not seen to circumnavigate authority, especially that of the HMB, and with the support of the Board of Trustees or some of its members.
The outcome measures should be measured through a survey to determine the satisfaction of the staff; the desired outcome should be seen as staff, both research, and support, showing less inclination to leave their respective groups and/or the hospital. The disruption of the research agenda caused by the conflict and the staff reshuffle should return to optimum progression, as determined by past performance. Most importantly, the cordial relationship should be restored between the HMB and the BOT. (See Appendix 3)
Conclusion
The position of prestige that the center enjoys now was a result of the hard work and dedication of its founders. However, all this is at risk of being lost due to an avoidable problem; and that is easy to solve if only the concerned parties are willing and determined to work towards this end. Only through that will the hospital be saved from discredit and decline.
Reference list
Curtis K. A (1994). Attributional analysis of interprofessional role conflict. Social Science & Medicine, Volume 39, Issue 2, Pages 255-263.
Harolds J. and Wood B. P. (2006). Conflict Management and Resolution. Journal of the American College of Radiology, Volume 3, Issue 3, Pages 200-206.
Mrayyan M. T., Rola Modallal, Khitam Awamreh, Maysoun Atoum, Muna Abdullah, Samah Suliman (2008). Readiness of organizations for change, motivation and conflict-handling intentions: Senior nursing students’ perceptions. Nurse Education in Practice, Volume 8, Issue 2, Pages 120-128.
O’Mara K. (1999). Communication and Conflict Resolution in Emergency Medicine. Emergency Medicine Clinics of North America, Volume 17, Issue 2, Pages 451-459.
Skjørshammer M. (2001). Conflict management in a hospital – Designing processing structures and intervention methods. Journal of Management in Medicine. Volume: 15 Issue: 2 Pages: 156 – 166.