Essential Ethics for the Success of Organizations and Their New Leaders William Nelson, PhD Geisel School of Medicine at Dartmouth John Donnellan, MPA, FACHE NYU Robert F. Wagner Graduate School of Public Service Overview of Today s Session Objectives Participants will gain: Appreciation of ethics as the foundation and framework for health care delivery Knowledge of ethics principles that relate to today s health care environment An understanding of the relationship between ethics and law The ability to recognize and respond to ethical issues commonly encountered by health care managers An overview of the features of ethically grounded organizations An understanding of the characteristics of ethical leadership 2 1
Ethics Is the Foundation and Framework Foundation Ethics defines what and who the organization is at its core; its mission and values Framework Ethics serves as how the organization will fulfill that foundation in its practices and culture And, how it will address ethics conflicts when they arise Organization s Culture and Practices Organization s Mission and Values Structure and System of Care Common Morality Clinician-Patient Encounters 2
Health Care Ethics We traditionally think of Ethics in Health Care in 3 buckets : Clinical ethics Managerial and organizational ethics Research and quality improvement ethics 5 Ethical Conflicts Occur when there is uncertainty, a question, or a conflict regarding competing ethical principles, personal values, or professional and organizational ethical standards of practice. Or, when one considers violating an ethical principle, personal value, or ethical standard of practice 6 3
Relationship between Ethics, Law, and Compliance Health care ethics overlap with law and compliance but is not the same Compliance and ethics overlap: Foster fulfillment of mission, vision and values of the organization Reflect an organization s commitment to shared values of society However, they differ in important ways 7 Relationship between Ethics, Law, and Compliance Compliance Programs are grounded in law, regulation, organizational, third party requirements Establish operational norms; minimally acceptable standards of conduct Procedural expression of organizational and community values Rarely provide conclusive guidance when ethical conflicts arise 8 4
Relationship between Ethics, Law, and Compliance Ethics programs are grounded in an organization s shared values (i.e. beneficence, non maleficence, respect for persons, honesty, etc.) Specifically designed to clarify uncertainty or resolve ethical conflicts, in accordance with the organization s shared values 9 Impact of Ethical Challenges Ethical conflicts have a significant impact: Staff caregiver stress, morale, job turn over, diverted staff time Patients patient satisfaction, self referrals Organizations culture professionalism, quality of care Relationship with community public image and relations, philanthropic giving Regulations Joint Commission standards Organizations bottom line cost of ethics conflicts* * Nelson WA, Weeks WB, Campfield JM. The organizational costs of ethical conflicts. Journal of Healthcare Management 2008 Jan Feb;53(1):41 52. 10 5
Ethical Issues in HC Organization & Mgmt Codes of Professional Ethics American College of Healthcare Executives Code organized by 6 key responsibilities: Responsibility to the profession Responsibility to patients/persons served Responsibility to organization Responsibility to employees Responsibility to community/society Duty to report 11 Ethical Issues in HC Organization & Mgmt Leaders of healthcare organizations are responsible for: Assessing & improving the quality of care Assuring access to care, consistent with the organization s mission Assuring an institutional culture consistent with the organization s mission Assuring the financial integrity of the institution Assuring institutional compliance 12 6
Ethical Issues in HC Organization & Mgmt Assessing & improving the quality of care What is measured? How transparent is performance data? What are the pros & cons of pursuing strategic excellence v. acceptable minimum? Are performance goals realistic and supported with resources? Have thresholds below which performance cannot fall been established and communicated? 13 Ethical Issues in HC Organization & Mgmt Access to care Is it assured, consistent with organizational mission? How? Are all relevant communities involved? Is it consistent with community demand/need? Must demand always be met? 14 7
Ethical Issues in HC Organization & Mgmt Assessing Organizational Culture Does it promote a community/socially responsible agenda? Is it a steward of community values & resources? i.e. Environmental Ethics Does it promote/reward/celebrate honesty & transparency? How easy is it to: Report a problem? Admit a mistake? Duty to report v. whistleblowing How is disclosure managed? How transparent is the organization? 15 Ethical Issues in HC Organization & Mgmt Assuring financial integrity No margin, no mission? Acceptable minimum v. strategic excellence? What happens when community need conflicts with fiscal solvency? Creating demand v. meeting demand (including unrecognized or unrealized demand) 16 8
Ethical Issues in HC Organization & Mgmt Assuring Institutional Compliance Ethical business practices Internal controls and fraud prevention What happens when one s personal or professional interests conflict, or appear to conflict, with their duty to protect the interests of patients or staff, conflicts with loyalty to the organizational? 17 Case Discussion Ms. Crimson, CEO The financial outlook for Sunny Springs Health Care is tenuous. Diagnostic services, including both radiology and laboratory, were among the few profitable services at the organization. Patients needing CT and MRI scans are being sent to a larger hospital 29 miles away. The CEO s (Ms. Crimson s) previous hospital is interested in selling their 16 slice CT scanner unit at a very reasonable price. Installing a high quality refurbished scanner will increase the radiology department workload and improve Sunny Springs bottom line. The CFO thinks this is a fabulous idea. The medical staff does not. 18 9
Case Discussion Ms. Crimson, CEO Is this an ethical problem? What are the relevant ethical facts? How should Sunny Springs Health Care balance its financial health with quality of care concerns? What process should Sunny Springs Health Care use to access the various potential benefits and harms in the acquisition of the CT scanner? What are the ethical implications of promoting a service that may possibly become a source of supply sensitive care concerns? What action should Ms. Crimson take? What is the ethical basis for your decision? 19 Features of an Ethical Organization 1. Ethical leadership there is no leadership tool more powerful than your own example as someone who consistently demonstrates the importance ethics and the organization s values 2. Integrated ethical values mission, vision and values are fully integrated into the life and culture of the organization 3. Ethics grounded clinical and administrative practices consistent with organizational values; evidence based; and, consistently applied and monitored 4. Ethics program an effective clinical and administrative resource that integrates ethics throughout the organization by promoting and clarifying ethical practices 20 10
What Makes an Ethical Leader? By communicating, through words and actions, examples of the right acts, the ethical leader will: Motive staff to perform the right acts Provide staff the freedom to perform the right acts Empower staff to be able to perform the right acts 21 Takeaways Ethical organizations do not just happen high performing, ethical organizations have: Integrated shared ethical values throughout the organization Ethically grounded clinical and administrative practices that reflect evidence, quality and value Effective ethics programs that can assist in effectively addressing ethical conflicts Ethical Leadership 22 11
It often requires more courage to dare to do right than to fear to do wrong. - Abraham Lincoln 23 Suggested Readings ACHE Code of Ethics, November 2011 American College of Physicians Ethics Manual, 6th edition. Ann Intern Med. 2012; 156(1), Part 2: 73 103 Brody H. From an Ethics of Rationing to an Ethics of Waste Avoidance. New England Journal of Medicine 2012; 366:1949 1951 Darr K. Ethics in Health Services Management. 5th ed. Baltimore, MD: Health Professions Press; 2011. Freeman RE, Stewart L. Developing Ethical Leadership. Business Roundtable for Corporate Ethics. 2006 24 12
Suggested Readings (continued) Nelson W. An Organizational Ethics Decision Making Process. 2005 Healthcare Executive. 20(4):9 14 Nelson WA. Healthcare Management Ethics: Comparing Ethics and Compliance programs. Healthcare Executive. 2012; 27(4): 46 49. Wennberg D, Berkson D, Rider B. Addressing Overuse, Underuse, and Misuse of Care. Healthcare Executive 2008; July/Aug: 9 14 25 William Nelson, PhD William Nelson, MDiv, PhD is Associate Professor of Community and Family Medicine, and The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Hanover, NH; also, Adjunct Associate Professor, New York University School of Public Service. His scholarly activities focus on the linkage between ethics, quality and value. Previously, he was Chief, Ethics Education at the VA s National Center for Ethics in Health Care. He was the recipient of the US Congressional Excalibur Award for Public Service and a W.K. Kellogg National Leadership Fellowship. In 2004, the VA established the William Nelson Award for Excellence in Health Care Ethics. In 2006 Dr. Nelson was awarded an Honorary Doctorate from Elmhurst College. Author of numerous articles and book chapters; Principal Investigator of research and is the ethics consultant to ACHE. Dr. Nelson co edited Managing Ethically: An Executive s Guide and Handbook for Rural Health Care Ethics. He is a regular contributor to the ethics column in Health Executive and was awarded a Honorary FACHE at this year s ACHE Congress. You can reach Dr. Nelson at William.A.Nelson@dartmouth.edu 26 13
John Donnellan, MPA, FACHE John Donnellan, MPA FACHE is Adjunct Professor of Health Policy & Management at the NYU/Wagner Graduate School of Public Service in NYC. Professor Donnellan joined the faculty at NYU/Wagner in 2009 as the inaugural Robert Derzon Visiting Professor of Health. At NYU/Wagner, Professor Donnellan teaches health care management, management ethics and compliance in nonprofit corporations. He was recognized in 2011 as NYU/Wagner s Distinguished Adjunct of the Year. In 2009 Professor Donnellan retired after forty years in Federal Service. From 1991 until his retirement he served as Director/CEO of the VA Medical Center, New York and later the VA New York Harbor Healthcare System. In 1999 he was awarded the President s Distinguished Senior Executive Rank Award in recognition of his leadership in federal service. In addition to teaching at NYU/Wagner, Professor Donnellan serves as Co Chairperson of the Scientific Review Committee of the NYU NYC Health and Hospital Corporation Clinical Translational Science Institute. You can reach Mr. Donnellan at john.donnellan@nyu.edu 27 14