DIGNITY HEALTH STANDARDS for MISSION INTEGRATION

DIGNITY HEALTH STANDARDS for MISSION INTEGRATION

Dear Dignity Health Colleague: Mission Integration is all of the processes, programs and relationships that express a spirit that is deeply woven into the fiber of organizations; a spirit that is expressed in a deep commitment and sense of purpose; rooted in the values and traditions of the organization; and evident in a special spirit that is part of the culture. It is what draws people to the organization. We thank you for your continued leadership and commitment to Dignity Health s mission and values. You and your local leadership have our personal support and the support of senior staff and system mission leaders. The Dignity Health Standards for Mission Integration reflect the future we, as a system, are aspiring to realize. The Standards provide us with a framework to identify, measure and improve the ways in which the mission of our health care ministry is carried out. They also are a tool that will help us assess how our values are being lived out in the day-to-day operations of our organization. Each facility is expected to establish and support an overall mission integration process, supported by an annual plan. We invite you to join us in a renewed commitment to the vision and values of Dignity Health and to our mission of advancing the healing ministry of Jesus. Lloyd H. Dean President /CEO Bernita McTernan Executive Vice President, Sponsorship, Mission Integrity and Philanthropy

OUR MISSION Dignity Health and its founding congregations are committed to furthering the healing ministry of Jesus. We dedicate our resources to delivering compassionate, high quality, affordable health services; serving and advocating for our sisters and brothers who are poor and disenfranchised; and partnering with others in the community to improve the quality of life. OUR CORE VALUES Dignity Health is committed to furthering this mission, while demonstrating the values of Dignity, Collaboration, Justice, Stewardship and Excellence. TABLE OF CONTENTS Local Indicators Organizational Identity...1 Spirituality...2 Ethics...3 Community Health...5 System Indicators Organizational Identity...8 Spirituality...10 Ethics...10 Community Health...12

LOCAL INDICATORS Local Indicators show how the Standards for Mission are lived day to day in the work of healing. Organizational Identity The Dignity Health mission and core values shape the organization s vision, strategic planning and operational decisions. Key constituencies understand and advance the mission, core values and heritage of Dignity Health. Dignity Health promotes diversity in the workplace. Dignity Health maintains dialogue with local bishops and church leaders on matters that will have a significant impact on the ministry. Standard 1 The Dignity Health mission and core values shape the organization s vision, strategic planning and operational decisions. A. Facility leadership is selected and evaluated on the basis of professional competence and behaviors that exemplify the Dignity Health mission and core values. B. Local planning, budgeting and capital requests are grounded in mission and core values. C. The Developing Organizational Capacity (DOC) Survey and other employee surveys are used to evaluate, act on and improve organizational effectiveness. D. Quality improvement processes are evident in each facility as expressions of the organization's commitment to excellence. E. Community Benefit programs, marketing, communications, and promotional activities clearly reflect the mission and core values of the organization. F. The Dignity Health system logo is displayed in signage and used in business documents and communication materials in accordance with the Dignity Health Identity Guidelines. Standard 2 Key constituencies understand and advance Dignity Health s mission, core values and heritage. A. Senior leadership assures that the strategic direction of the facility and decisions concerning human, financial, material and ecological resources are made in alignment with the Dignity Health mission and core values. B. At each facility a designated member of the senior management team, with professional education in mission leadership is accountable for initiating and coordinating mission integration. Page 1

C. Employees, managers, volunteers, physicians and Board Members receive initial orientation and on-going opportunities to learn about Dignity Health s mission, vision, core values, and the history and heritage of the facility and the implication for their work. D. Expressions of the history, heritage and mission of the facility are prominently displayed. E. An annual facility Mission Integration Report is developed and presented to Hospital Boards according to System guidelines. F. The mission leader coordinates participation in a nomination and selection process for the facility Values in Action Award. G. Community Board members and facility leadership are selected and evaluated on the basis of professional competence and congruence with the Dignity Health core values. Standard 3 Dignity Health promotes diversity in the workplace. A. Facility management recognizes there are many facets of diversity in the workplace and promotes a culture of respect and inclusion. B. The facility acts in compliance with Equal Employment Opportunity Commission guidelines and Affirmative Action regulations. Standard 4 Dignity Health maintains dialogue with local bishops and church leaders on matters that will have a significant impact on the ministry. A. Facility leadership promotes outreach and collaboration with local faith communities to enhance the spiritual care of their patients and the communities they serve. B. To strengthen the Catholic health ministry, System leadership, in collaboration with facility leadership, maintains ongoing communication with bishops in the dioceses where Dignity Health has a presence. Spirituality Dignity Health embraces the spiritual dimension of life and is committed to providing Spiritual Care Services to patients, families and caregivers. Dignity Health promotes spirituality in the lives of its employees and in the work of the organization. Standard 5 Dignity Health embraces the spiritual dimension of life and is committed to providing Spiritual Care Services to patients, families and caregivers. A. A designated spiritual care leader, trained with professional certification in Chaplaincy, is responsible for coordinating all Spiritual Care Services. B. The provision of spiritual care in each facility is integrated with patient care processes. Page 2

C. Each facility provides culturally competent patient/family care that recognizes the patient s and family s psycho-social-spiritual needs. D. Spiritual Care Services at each facility are developed to include support for the variety of beliefs represented by those served. E. Spiritual Care Services develops a system of accountability that measures the quantitative and qualitative aspects of its services and promotes continuous improvement of outcomes. F. Spiritual Care Services promotes the certification of its chaplains, continuing education and Clinical Pastoral Education. G. Religious celebrations are offered in a manner sensitive to the cultural and faith diversity of the persons in Dignity Health facilities. The sacraments and rituals of the Catholic Church and of other faith traditions are made available whenever possible. Standard 6 Dignity Health promotes spirituality in the lives of its employees and in the work of the organization. A. Each facility has a chapel or designated space available for reflection, prayer and/or worship. B. Each facility creates an environment conducive to healing in its design of internal and external space, use of art, gardens, music, private space and technology. C. Each facility marks special occasions and recognizes heritage days with prayer and rituals that affirm the spiritual dimension of the organization and its mission. D. All gatherings and meetings begin with a prayer/inspirational reflection to help people connect with the deeper purpose of their work. E. Managers and employees participate in educational opportunities that promote their ongoing awareness of the spiritual dimension of their work and the ministry of healing. Ethics Dignity Health fosters a just work environment characterized by respect for the dignity of persons, and opportunities for growth and development. Dignity Health is guided by the social teachings of the Catholic Church, the Ethical and Religious Directives for Catholic Health Care Services and the Dignity Health Statement of Common Values. Dignity Health promotes ethical integrity in organization and business practices and in patient care. Dignity Health promotes equity in the provision of care and respects the right of each person to participate in health care decisions. Standard 7 Dignity Health fosters a just work environment characterized by respect for the dignity of persons and opportunities for growth and development. Page 3

A. Human Resource policies and procedures, selection criteria, performance management, salaries, benefits and rewards are reviewed regularly for consistency with the Dignity Health mission and core values. B. Management works collaboratively with employees, physicians, volunteers and union leadership to create an effective, healthy and safe work environment. C. Resources are invested in employee education and professional development. D. Facility leadership demonstrates understanding of Catholic social teachings by engaging employees in dialogue about issues affecting the conditions of their work. E. Management provides employees with accurate and factual information to support an informed choice and encourages workers to vote during organized labor campaigns. Standard 8 Dignity Health is guided by the social teachings of the Catholic Church, the Ethical and Religious Directives for Catholic Health Care Services and the Dignity Health Statement of Common Values. A. The Ethical and Religious Directives for Catholic Health Care Services and the Dignity Health Statement of Common Values are considered, as appropriate, in the development of policies and in the provision of health care services. B. Employees are educated about the social teachings of the Catholic Church, the Ethical and Religious Directives and the Dignity Health Statement of Common Values. Standard 9 Dignity Health promotes ethical integrity in organization and business practices and in patient care. A. Each facility uses a structured process of ethical reflection for strategic, business and management decision-making and priority setting. B. Employee recruitment and evaluation integrates measures to gauge congruence with Dignity Health core values. C. Each facility has an Ethics Committee for clinical ethics policy development, education and case consultation, or has the resources of an Ethics Committee available to it. Each Ethics Committee: - Is appropriately chartered within the organization; - Maintains minutes for submission to the appropriate local hospital Board; - Has interdisciplinary membership; - Engages in regular education for itself, the organization and the medical staff; - Has guidelines for policies and case consultation. Page 4

D. Each facility integrates Dignity Health s Philosophy of Mistake Management, Event Reporting Policy and Safe Harbor Provision into employee orientation and training programs, and promotes a non-punitive environment and culture that supports timely and appropriate reporting of mistakes. E. Each facility receives a rating of one (1) or two (2) in the Organization Ethics section of its Joint Commission survey. Standard 10 Dignity Health promotes equity in the provision of care and respects the right of each person to participate in health care decisions. A. Each facility provides care to all persons regardless of age, gender, race, socio-economic or immigrant status, sexual orientation, gender identity or religious affiliation. B. Each facility provides linguistically and culturally sensitive care to patients. C. Each facility provides a trained and interdisciplinary staff to educate and assist patients or the patient s surrogate decision-maker in understanding and expressing treatment decisions. D. Each facility receives a rating of one (1) or two (2) in the patient rights section of its Joint Commisssion survey. E. Educational opportunities for patients, staff and the community regarding Patient Rights, executing Advance Directives, and supportive care of the dying are provided. F. Each facility assures that the choices of patient, family or surrogate decision-maker, which are consistent with Dignity Health policies, are respected. G. Each facility has policies and procedures assuring continuous improvement in patient care including effective pain management and palliative care. H. Each facility allocates ample resources for palliative care. I. Clinical research activities (including Institutional Review Board [IRB] operations) are conducted in accord with the terms of the Dignity Health Federal-wide Assurance and with Dignity Health clinical research policies and procedures. Community Health Dignity Health partners with others in the community to improve the quality of life. Through effective advocacy efforts, Dignity Health addresses the social, political and economic structures that impact the health of persons, especially those most vulnerable. Dignity Health exercises responsible stewardship of the environment and partners with others to advance ecological initiatives. Standard 11 Dignity Health partners with others in the community to improve the quality of life. Page 5

A. Each facility participates collaboratively with local stakeholders in a community health assessment that: Page 6 - Establishes priorities; - Develops a plan to address identified needs; - Integrates community health priorities into the strategic planning and annual budgeting process. B. Each facility partners with other Catholic, private and public organizations in the community to address community health priorities. C. Each facility budgets adequate financial resources to hire competent and effective staff to plan, develop, implement and manage community benefit initiatives. D. Community benefit programming incorporates the following core principles: Principle 1: Principle 2: Principle 3: Principle 4: Principle 5: Address those with disproportionate unmet needs (those most vulnerable) Seek first and foremost to support communities with a high rate of unmet health-related needs and/or high-risk populations. Primary Prevention. Endeavor to identify and remedy the underlying causes of persistent health problems. Continuum of Care. Establish operational connections between clinical programs and community health improvement activities, ensuring that the right level of service is accessible at the right time and in the right place. Building Community Capacity. Work in partnership with the community to ensure that the charitable resources are utilized to mobilize and build the capacity of existing community assets. Collaborative Governance. Engage diverse community stakeholders in the selection, design, implementation and evaluation of programs to foster better design and mutual accountability. E. Each facility uses the Community Benefit Inventory for Social Accountability to identify, track, quantify and report its community benefit initiatives. F. Each facility president and board participates in the process of establishing priorities, plans and programs for community benefit, approves the community benefit plan and monitors progress toward identified goals. Standard 12 Through effective advocacy efforts, Dignity Health addresses the social, political and economic structures that impact the health of persons, especially those most vulnerable. A. Each facility has a designated coordinator of advocacy efforts and an advocacy team responsible for implementing system-wide and facility-specific advocacy priorities B. Each facility proactively builds relationships with elected officials and community advocacy partners.

Standard 13 Dignity Health exercises responsible stewardship of the environment and partners with others to advance ecological initiatives. A. Each facility develops and implements policies to address: - Waste minimization; - Energy and water conservation; - Reduction of greenhouse gas emissions. B. Each facility/service area has an Environmental Action Committee that: - Includes representation from patient services, purchasing, engineering, maintenance, housekeeping, dietary, pharmacy, infection control, laboratory, safety & security, and administration; - Sets annual goals for improved environmental performance and monitors progress toward those goals; - Submits quarterly and annual reports to the System; - Seeks opportunities to partner with others in the community in support of ecological projects; - Educates employees on environmental issues. C. Safeguarding environmental resources is referenced in employee orientation, reorientation, position descriptions and annual evaluations. Page 7

SYSTEM INDICATORS System Indicators are actions or behaviors by the Dignity Health Board of Directors, Executive Leadership Team, Religious congregation representatives or System office workers that help assure that the systems and structures are in place to meet the Standards for Mission Integration. System Indicators are a means of accountability on the part of leaders at Dignity Health. Organizational Identity The Dignity Health mission and core values shape the organization s vision, strategic planning and operational decisions. Key constituencies understand and advance Dignity Health s mission, core values and heritage. Dignity Health promotes diversity in the workplace. Dignity Health maintains dialogue with local bishops and church leaders on matters that will have a significant impact on the ministry. Standard 1 The Dignity Health mission and core values shape the organization s vision, strategic planning and operational decisions. A. System leadership is selected and evaluated on the basis of professional competence and behaviors that exemplify the Dignity Health mission and core values. B. System planning, budgeting and capital requests are grounded in mission and core values. C. System leadership assesses the organizational culture to evaluate the integration of mission and values in the workplace. Follow-up strategies are developed to address issues that have a direct impact on mission and values integration. D. System-wide quality improvement processes are evident expressions of the organizations commitment to excellence. E. Community Benefit programs, marketing, communications, and promotional activities clearly reflect the philosophy, mission and core values of the organization. F. The Dignity Health system logo is displayed in signage and used in business documents and in communication materials, in accordance with the Dignity Health Identity Guidelines. Standard 2 Key constituencies understand and advance Dignity Health s mission, core values and heritage. A. Dignity Health s Sponsorship Council and Board of Directors assure that Dignity Health s vision, decisions, and resources advance the mission, and express a values-based organization that reaches out in response to the communities served. B. Dignity Health Leadership and Sponsorship Council effectively engage in discussions and dialogue regarding matters pertinent to Dignity Health s mission. Page 8

C. Senior leadership assures the strategic direction of Dignity Health and decisions concerning, human, financial, material and ecological resources are made in alignment with the Dignity Health mission and core values. D. The Executive Vice President of Sponsorship, Mission Integrity and Philanthropy is a member of the Executive Leadership Team. E. System Mission leaders oversee mission integration and communicate progress on mission initiatives to all constituents. F. Employees, Boards and Sponsors receive initial and continuing orientation to the Dignity Health mission, vision, core values, and the history and heritage of the founding congregations and community hospitals. G. Expressions of the heritage and mission of the founding congregations of Dignity Health and all of our hospitals are displayed in the System Office. H. An annual system-wide Mission Integration Report is developed and presented to the Board, Sponsorship Council and hospital Boards. I. System leadership facilitates the annual System Values in Action Award recognizing persons and initiatives that express the Dignity Health core values. J. Board members are selected and evaluated on the basis of professional competence and congruence with Dignity Health mission and core values. K. System leadership assures that those serving in governance and management roles throughout the System engage in reflection and dialogue on values issues that have implications for health care and establish policies as appropriate to address these issues. L. System Leadership develops effective structures for sharing best practices and for professional development of mission personnel. Standard 3 Dignity Health promotes diversity in the workplace. A. System leadership assures development and implementation of a system-wide strategic diversity plan that includes: Diversity awareness to enhance workforce competence/productivity and diverse representation; Compliance with EEO/AA statutes and regulations; Accountability for diversity metrics to determine progress in recruiting and retaining a highly skilled, diverse workforce and Boards. Standard 4 Dignity Health maintains dialogue with local bishops and church leaders on matters that will have a significant impact on the ministry. Page 9

A. System leadership, in collaboration with facility leadership, maintains ongoing communication with bishops in the dioceses where Dignity Health has a presence to strengthen the Catholic health care ministry. Spirituality Dignity Health embraces the spiritual dimension of life and is committed to providing Spiritual Care Services to patients, families and caregivers. Dignity Health promotes spirituality in the lives of its co-workers and in the work of the organization. Standard 5 Dignity Health embraces the spiritual dimension of life and is committed to providing Spiritual Care Services to patients, families and caregivers. A. System leadership, in collaboration with local leadership, assures that spiritual care is integral to the delivery of care at each facility and provides the appropriate support, resources and leadership to ensure excellence in this aspect of ministry. B. System leadership enhances the provision of spiritual care through the integration of spiritual services in multidisciplinary initiatives for policy development, ethics, and quality improvement. C. System leadership develops effective structures for on-going networking, sharing of best practices and professional development of spiritual care personnel. Standard 6 Dignity Health promotes spirituality in the lives of its co-workers and in the work of the organization. A. Artistic works of an inspirational and spiritual nature are displayed in the System Office to express the Dignity Health ministry of healing. B. The System marks special occasions and recognizes heritage days with prayer and rituals that affirm the spiritual dimension of the organization and its mission. C. All gatherings and meetings begin with a prayer/reflection to help people connect with the deeper purpose of their work. D. The System facilitates educational opportunities for employees and managers that promote their ongoing awareness of the spiritual dimension of their work and the ministry of healing. E. A space designated for quiet and reflection is provided in Dignity Health System Office. Ethics Dignity Health fosters a just work environment characterized by respect for the dignity of persons and opportunities for growth and development. Dignity Health is guided by the social teachings of the Catholic Church, the Ethical and Religious Directives for Catholic Page 10

Health Care Services and the Dignity Health Statement of Common Values. Dignity Health promotes ethical integrity in organization and business practices and in patient care. Dignity Health promotes equity in the provision of care and respects the right of each person to participate in health care decisions. Standard 7 Dignity Health fosters a just work environment characterized by respect for the dignity of persons and opportunities for growth and development. A. System Human Resources leaders assure regular review of policies so that they are consistent with the Dignity Health mission and core values. B. The Mission Committee contributes to the integration of Dignity Health mission and values at the system office. C. System leadership uses the Developing Organizational Capacity (DOC) and employee surveys to evaluate, act on and improve organizational excellence. Follow-up strategies are developed to address issues that have a direct impact on mission and values integration. Standard 8 Dignity Health is guided by the social teachings of the Catholic Church, the Ethical and Religious Directives for Catholic Health Care Services and the Dignity Health Statement of Common Values. A. System leadership assures that policies and practices are consistent with the social teachings of the Catholic Church, the Ethical and Religious Directives for Catholic Health Care Services and the Dignity Health Statement of Common Values. B. Employees are educated about the social teachings of the Catholic Church, the Ethical and Religious Directives and the Dignity Health Statement of Common Values. Standard 9 Dignity Health promotes ethical integrity in organization and business practices and in patient care. A. The System uses a structured process of ethical reflection for strategic, business and management decision-making and priority setting. B. The System supports and encourages socially responsible employee relations, purchasing and investing. C. The System provides education to its Boards, executives and management teams on ethics and justice. D. The System assures that each facility s Ethics Committee: - Is appropriately chartered within the organization; Page 11

- Maintains minutes for submission to the appropriate local Hospital Board; - Has interdisciplinary membership; - Engages in regular education for itself, the organization and the medical staff; - Has guidelines for policies and case consultation. E. The System devotes adequate resources to ensure that mistakes made by Dignity Health are handled in accordance with Dignity Health core values. Standard 10 Dignity Health promotes equity in the provision of care and respects the right of each person to participate in health care decisions A. The System provides consultation and educational resources to support facilities in addressing ethics and justice issues. B. The System considers the diverse linguistic and cultural needs of patients when setting productivity standards. C. The System tracks data regarding patient care and develops plans to improve outcomes in patient care. D. The System provides educational resources and facilitates the sharing of best practices in patient care. E. The system allocates ample resources for palliative care. Community Health Dignity Health partners with others in the community to improve the quality of life. Through effective advocacy efforts, Dignity Health addresses the social, political and economic structures that impact the health of persons, especially those most vulnerable. Dignity Health exercises responsible stewardship of the environment and partners with others to advance ecological initiatives. Standard 11 Dignity Health partners with others in the community to improve the quality of life. A. The System develops, implements and monitors policies and processes to advance effective community benefit programming. B. The System facilitates collaborative partnerships to improve the health status and wellbeing of persons in Dignity Health service areas and other communities in need. C. The System sets the expectation that community benefit is integrated into local strategic planning and budgeting processes. D. The Dignity Health Board reviews the annual system-wide community benefit report. E. The System oversees the Community Investment and Grants processes. Page 12

Standard 12 Through effective advocacy efforts, Dignity Health addresses the social, political and economic structures that impact the health of persons, especially those most vulnerable. A. System advocacy priorities address issues related to: - Providing the resources needed to effectively care for those most vulnerable; - Promoting community health; - Advancing ecological initiatives. B. The System devotes resources (time and personnel) to public policy and shareholder advocacy. C. Dignity Health collaborates with other organizations that share our values to coordinate public policy and shareholder advocacy efforts. Standard 13 Dignity Health exercises responsible stewardship of the environment and partners with others to advance ecological initiatives. A. The System develops and implements policies for the reuse, recycling and conservation of Earth's resources. B. The System facilitates quarterly and annual environmental (Ceres) reporting and annual system-wide goal setting for improved environmental performance. C. The System conducts environmental audits of each facility on a regular basis. D. The System provides educational forums on environmental issues & best practices. Page 13