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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 n The New York Times decried “poor management, a history of retaliation toward employees, cumbersome and outdated technology, and a shortage of doctors and nurses and physical space to treat patients.”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