Download Institutional Integrity and Organizational Ethics

Institutional Integrity and
Organizational Ethics
Carol Taylor, PhD, RN
Georgetown University School for Nursing and Health Studies
[email protected]
The crisis in the the US Veterans Affairs
Department is fundamentally a crisis of ethics,
according to the former hospital ethicist at the
Philadelphia Veterans Affairs Medical Center,
Evelyne Shuster.
n  The New York Times decried “poor
management, a history of retaliation toward
employees, cumbersome and outdated
technology, and a shortage of doctors and
nurses and physical space to treat patients.”
The Wall Street Journal lamented a “corrosive
culture” which had damaged patient care.
n 
Million Dollar Question
n  But
not long ago, VA was at the forefront
of quality care and patient safety. It had
identified weaknesses in its ethical culture
and had set up a multi-million dollar
program to deal with it called
Integrated Ethics. How did things go so
wrong?
Workplace Violence
n 
n 
n 
n 
n 
n 
n 
n 
n 
almost 75% of all workplace assaults between 2011 and 2013
happened in healthcare settings;
80% of emergency medical workers will experience violence during
their careers;
78% of emergency department physicians nationwide report being
the target of workplace violence in the past year;
100% of emergency department nurses report verbal assault and
82.1% report physical assault during the last year;
40% of psychiatrists report physical assault;
the rate of workplace violence among psychiatric aides is 69 times
higher than the national rate of workplace violence;
61% of home healthcare workers report violence annually; and
family physicians are also at high risk, although limited data exist in
the outpatient setting.
N Engl J Med. 2016;374:1661-1669
Medical Error
n  Is
medical error really the third leading
cause of hospital deaths…?
"The five most dangerous words in business
may be 'Everybody else is doing it.' "
Warren Buffett
Objectives
Upon completion of this session participants will be
able to:
n  Define ethics, moral agency, and moral integrity
n  Describe how both individuals and institutions develop
moral agency and integrity and the consequences of
honoring or dishonoring integrity
n  Analyze how an institution’s mission, vision and core
values influence institutional decision making, behavior
and integrity
n  Identify common ethical challenges in the workplace and
strategies for resolving these problems
n  Contrast integrity-based and compliance-based
organizational ethics programs
Objectives
(time permitting…)
Upon completion of this session participants will be
able to:
n  Describe the hallmarks and challenges of quality
institutional ethics programs
n  Distinguish ethics concerns/challenges and related
resources from legal, safety/quality, human resources,
etc. concerns/challenges
n  Develop strategies for raising ethical awareness within
institutions and bringing forward ethical challenges
n  Utilize systematic processes including a values-based
decision-making model for resolving organizational
ethical challenges
STARTING ASSUMPTIONS
Glaser’s three realms of ethics
Societal Realm
Organizational Realm
Individual Realm
Clarifying Concepts
n  Ethics
n  Moral
Agency
n  Moral Integrity
What is Ethics?
What is Ethics?
n
Ethics is the formal study of who we
ought to be and how we should make
decisions and behave in light of our
identity
Dan Callahan’s Three
Foundational Questions
What kind of person ought I be in order to
live a moral life and make good ethical
decisions?
n What are my duties and obligations to
other individuals whose life and well-being
may be affected by my actions?
n What do I owe the common good or the
public interest, in my life as a member of
society?
n
Distinguishing Clinical and
Organizational Ethics
n 
Clinical ethics is an interdisciplinary activity to
identify, analyze, and resolve ethical problems
that arise in the care of particular patients. The
major thrust of clinical ethics is to work for
outcomes that best serve the interests and
welfare of patients and their families [J. Fletcher, The
Bioethics Movement and Hospital Ethics Committees, Maryland Law
Review 50 (1991):859n, note 1.].
Organizational Ethics
n  The
intentional use of values to guide the
decisions of a system.
n  Objective:
strong “FIT” between the
system’s stated mission and decision
making at all levels of the system
Health Care Delivery and Value
Commitments (Nairn article)
Promote and defend human dignity
n Attend to the whole person
n Care for poor and vulnerable persons
n Promote the common good
n Act on behalf of justice
n Steward resources
n Act in communion with the Church
n
Values-Based Ethical
Decision-Making
n  Step
One: Clarify the Ethical Conflict
n  Step Two: Identify All of the Affected
Stakeholders and Their Values
n  Step Three: Understand the Circumstances
Surrounding the Ethical Conflict
n  Step Four: Identify the Ethical
Perspectives Relevant to the Conflict
Step Five: Identify Different Options for
Action
n Step Six: Select Among the Options
n Step Seven: Share and Implement the
Decision
n Step Eight: Review the Decision to Ensure
It Achieved the Desired Goal
n
[Nelson, W.A. (July/Aug 2005). An organizational ethics decisionmaking process. Healthcare Executive, 9-14.]
n  See
the Bon Secours Health System
Ethical Discernment Process--handout
Difference between Ethics and
Compliance
The compliance strategy, which is
predominantly lawyer driven, meets the
basic needs for legal compliance.
n The integrity-based strategy is
characterized by a conception of ethics as
a driving force of an enterprise. Lynn Sharpe
n
Paine
Compliance Strategy
Integrity Strategy
Ethos
Conformity with externally
imposed standards
Self-governance according
to
chosen standards
Objective
Prevent criminal misconduct
Enable responsible conduct
Leadership
Lawyer-driven
Management-driven with aid
of lawyers, HR, others
Methods
Education, reduced
discretion, auditing and
controls, penalties
Education, leadership,
mentoring, accountability,
organizational systems and
decision processes (“centers
of ethical responsibility”)
auditing and controls,
penalties
Behavioral
Assumptions
Autonomous beings guided
by material self-interest
Social beings guided by
material self-interest, values,
ideals, peers
What is moral agency?
This requires formation…
We know the right thing to do
but it is almost impossible…
Deficient moral agency
n Ethical Distress
n à Ethical Residue
n à Disengagement
n
What is Moral Integrity?
Integrity:
1.  soundness of and adherence
to moral principle and
character; uprightness and
honesty.
2.  the state of being whole,
entire, or undiminished.
3.  a sound, unimpaired, or
perfect condition.
From Webster’s Encyclopedic
Unabridged Dictionary of the
English Language
Snicker Test
Why be a person/ministry of
Integrity?
n  “American
Baptist Homes of the West will
continue to hold the trust of its
constituency by keeping its promises with
integrity, stability, and intentional ethical
behavior in the provision of quality
services for older persons”
Effective Ethics Programs
Veterans Association’s Integrated Ethics Program
n  respond
to ethical questions at the level of
actions and decisions through
Ethics Consultation;
n  address ethics quality gaps at the level of
systems and processes by applying a
quality improvement approach in
Preventive Ethics; and
n  foster a strong ethical environment and
culture through Ethical Leadership.
Ethical Culture
n  The
importance of creating a culture
where everyone does the right thing
simply because it is the right thing to do
Ethics Case versus Ethics Issue
§ Discrete
situation at a
particular time
§ A
question about what
is the best ethics
practice
§ Goal to improve ethics
quality by responding
to an ethics question
§ Ongoing
situation
involving organizational
systems & processes
§ A systemic gap between
current and best ethics
practice
§ Goal to improve ethics
quality by reducing ethics
quality gaps at a systems
level
What is Ethics Quality in
Health Care?
Decisions
Decisions
and
andactions
actions
(Ethics
(Ethics
Consultation)
)
Consultation)
(
Ethics)
Environment
VHA, National Center for Ethics in Health Care
Why Ethics Consultants Should Care about
Systems/Processes & Environment/Culture
Ethics cases are embedded in, and influenced
by, the larger organizational context
§  Many ethics cases have systems level causal
or contributory antecedents
§  Therefore, recurrent cases predict future
cases unless underlying systems issues are
identified and addressed
§ 
VHA, Natioanl Center for Ethics in Health Care
34
Why Ethics Consultants Should Care About
Systems/Processes & Environment/Culture
§
Ethics consultants are a limited resource and
have a stewardship interest in preventing the
recurrence of similar cases
VHA, Natioanl Center for Ethics in Health Care
35
Check out this resource
n
STRIVING FOR
EXCELLENCE
IN ETHICS
a resource for the catholic health ministry
http://chausa.org/
excellenceinethics/
n
There are two parts to the resource they
developed: a printed booklet and a
website. The booklet includes an
introduction, recommended standards for
eight core components of a robust ethics
service, and a tool for assessing a
particular organization’s performance with
regard to each component as well as each
of its standards
Components of a Robust Ethics
Service
n
n
n
n
n
Ethics expertise
Ethics committees
Consultation and
advisement
Education and
formation
Policy development
and review
n
n
n
Community
outreach
Institution
Integration
Leadership
support
CHA, Striving for Excellence in Ethics
Available at:
http://www.chausa.org/
Ethics_Overview.aspx
Are Health Care Ethics Program
Failing to Thrive?
n 
Evaluate present status and decide how the ethics program
can realistically enhance the parent organization
–  Involve administration, clinical staff, and other affected entities.
–  Decide where the program should go, what steps are necessary
to get there, and develop a timetable for change, asking for help
when needed
–  Check with other healthcare organizations and see how they are
responding
n 
Hire a consultant—Evaluation and advice from a
knowledgeable and experienced person can be invaluable
and, if major changes are likely, necessary. The consultant’s
work need not be overly expensive or time consuming.
Are Health Care Ethics Program
Failing to Thrive?
n
n
n
n
Reinvigorate ethics committee members with
educational programs and recruit new
members eager for challenge.
Involve administration and Board members in
the planning.
Obtain institutional buy-in at all affected
levels.
Monitor the committee’s function at regular
intervals to check for signs of incipient
malnutrition (Mills, Rorty & Spencer, HEC Forum, 2006, 285).
Organizational Integrity
Facilitating Variables
n  Leadership
must value institutional
integrity and communicate this clearly;
Senior leadership needs to be “on board”
n  The institutional mission, vision and values
must be known and alive!
n  Perception that it is “safe” to explore
areas of conflict/concern and that it is OK
for people to disagree
n  A
methodic process for reasoning about
ethical challenges to refute the notion that
ethics is merely a matter of opinion
n  Perception that this effort “pays off” in
better outcomes for patients, families and
staff, in short, it is “worth” the time,
energy and money invested
n  The institutional culture must support folks
doing the right thing because it’s the right
thing to do
n  A
critical mass within the institution must
be recognized for their moral agency
n  Institutional ethics resources must be
available and utilized
Constraining Variables
Leadership’s failure to value institutional
integrity
n Ethics is “one more program/initiative”:
this year we are doing Baldrige
n Failure to distinguish ethical dimension
from legal, compliance; to reduce ethics to
compliance
n Belief that ethics is a matter of personal
opinion; fear of “ethics police”
n
Resources
American College of Health Care Executives Ethics Toolkit: Introduction, An
organizational ethics decision-making process; Using ACHE’s code of ethics;
Using ACHE’s ethical policy statements; Using ACHE’s ethics selfassessment; Strengthening Ethical Decision Making, Additional ethics
resources. Available at:
http://www.ache.org/abt_ache/ethicstoolkit/ethicsTOC.cfm
n  Addressing ethics quality gaps on a systems level. The Joint Commission
Journal on Quality and Patient Safety. 38(3), 103-111. Epub 2012/03/23.
n  Bernhut, S. (March/April 2003). Leader’s edge. Lynn Sharp Paine on the
morally and ethically responsible corporation. Ivey Business Journal,
Reprint # 9B03TB04
n  Bishop, L.J. & Cherry, M.N. & Darragh, M. (Reprinted September 1999).
Scope Note: Organizational Ethics and Health Care: Expanding Bioethics to
the Institutional Arena. Retrieved May 15 from:
http://bioethics.georgetown.edu/publications/scopenotes/sn36.pdf
n 
n 
n 
n 
n 
n 
Catholic Health Association of the United States and Ascension
Health. (2011). Striving for Excellence in Ethics. A Resource for
the Catholic Health Ministry. http://www.chausa.org/
Foglia, M.B., Fox, E., Chanko, B. & Bottrell, M.M. (2012). Preventive
ethics: American Society for Bioethics and Humanities Task Force.
(2011). Core Competencies for Health Care Ethics Consultation, 2nd
ed. Glenview, IL: ASBH.
Fox, E; Myers, S. & Pearlman, R. A. (2007).
Ethics consultation in United States hospitals: a national survey .
American Journal of Bioethics 7(2): 13-25. Also see the companion
articles in this issue.
Justice, access to health care, and organizational ethics. In L.F.
Post, J. Blustein, & N.N. Dubler, (2007). Handbook for health care
ethics committees. Baltimore: The Johns Hopkins University Press,
pp. 120-136.
Kotter, J. P. (1996). Leading change. Boston: Harvard Business
School Press. N.B. Eight Errors Common to Organizational Change
Efforts and Their Common Consequences; The Eight-Stage Process
of Creating Major Change
Markkula Center for Applied Ethics: What is ethics? Making and ethical
decision. A framework for ethical decision making. Available at:
http://www.scu.edu/ethics/practicing/decision/
n McDaniel, C. Developmental and Psychometric Properties of the Ethics
Environment Questionnaire. Medical Care, 35(9): 901-914
n National Center for Ethics in Health Care. Integrated Ethics: Preventive
Ethics, Ethical Leadership, Education, Index of IE Resources. Available at:
http://www.ethics.va.gov/index.asp
n VitalSmarts, AORN, & AACN. Silence Kills and Silent Treatment. Available
at:
http://www.ache.org/abt_ache/ethicstoolkit/Ethical_Decision_Process.pdf
n
Small group discussion
Reflection Guide
n Advice to Secretary Robert A. McDonald as
he assumed leadership of Department of
Veterans Affairs
n Ethical Climate Assignment
n