By JULIE MINDA
It has been two decades since the Joint Commission called upon health care providers to determine how they could best anticipate the ethical concerns that can arise at an organizational level.
Like other health care organizations, Catholic facilities have experienced stops and starts in their efforts to set up formal approaches for accomplishing this. But many ministry systems now have effective organizational ethics programs in place and are attesting to their value.
"We've seen some good successes in the ministry" when it comes to setting up an infrastructure to address organizational ethics, said Ron Hamel, CHA senior director of ethics. "But it's been difficult for providers to move into this area. It takes time to do this, and it requires commitment on the part of everyone involved."
Initial hiccups
Organizational ethics deals with how an organization makes choices — how its leaders and staff think through the ethical implications of their decisions and of the policies and practices they put in place at every level of the organization. When the Joint Commission began including organizational ethics in its credentialing criteria in 1991, the concept was almost foreign to many in health care, according to organizational ethics pioneer Jack Glaser, who is senior vice president of theology and ethics and scholar in residence for St. Joseph Health System of Orange, Calif.
He had been hearing talk from industry front-runners about applying quality improvement principles to organizations' ethical practices and was excited about the prospect, but he found that few others in health care were thinking this way. "People didn't recognize this as an area of need at the time. This was before (health care providers) began taking a systematic approach to quality," he said.
There were other initial barriers to health care organizations adopting a formal, proactive approach to organizational ethics. Philip Boyle, vice president of mission and ethics for Newtown Square, Pa.-based Catholic Health East, said, "Organizational ethics is a very refractory concept — it's hard for people to get their heads around it."
Kirk Hanson, executive director of the Markkula Center for Applied Ethics at Santa Clara University in Santa Clara, Calif., added that some ministry facilities believed that since they were focused on their mission, they were by definition ethical and did not need a formal organizational ethics approach. The center partners with and consults for Daughters of Charity Health System of Los Altos Hills, Calif.
Hamel added that at many ministry facilities, the ethics experts were used to dealing with bedside clinical issues, not with organizational questions, and so they found it difficult to transition to a new model.
Trailblazer
Under Glaser's leadership, St. Joseph of Orange was among the first Catholic health care organizations to confront such challenges and create an organizational ethics program. Around 1999, the system began teaching staff at St. Joseph hospitals about organizational ethics and how it could benefit the system. Under the approach, St. Joseph asks colleagues to apply quality improvement principles to patient care scenarios that can evolve into ethical quandaries. It asks them to look for common problem points so they can put strategies in place to prevent avoidable difficulties.
Kevin Murphy is St. Joseph vice president of values integration, and he heads the organizational ethics effort that Glaser launched at the system. Murphy said when St. Joseph started the effort, "They thought it could all be up and done and running in just a few years. But that didn't happen. It is a process that involves deep cultural change."
To facilitate that change, the system has focused on staff formation and education in organizational ethics. It has created a database of more than 900 articles and other materials on organizational ethics topics for staff to use as a resource. It also offers staff a database in which they can log their efforts to improve organizational ethics. For instance, they track their work in improving ethical consultations, in communicating with colleagues and in getting feedback about their work.
Jennifer Shaw, director of theology and ethics, said the system has gained ground in addressing organizational ethics issues by encouraging staff to use a standard approach.
Fixing faults
Catholic Health Partners of Cincinnati has applied the organizational ethics approach primarily to its facilities' intensive care units, since that is where most medical ethical issues were arising, said John Gallagher, CHP corporate director of ethics. He explained that since faulty systems are what generally create the ethical problems that prompt consults, CHP's goal is to equip staff to be able to change the flawed systems, in large part by analyzing what's at the heart of the issues brought up in consults. For instance, such analysis has revealed that clinicians should try to talk in laymen's terms so as to avoid making patients and families feel perplexed by technical terminology, which can anger them and introduce a barrier between them and the care team.
Gallagher launched CHP's entry into organizational ethics about five years ago by visiting CHP hospitals' ICUs and talking with staff about their frustrations and the difficult cases they encounter. He used this frontline intelligence as he talked with CHP leaders in the ICU and on ethics committees about how to communicate and work with ICU staff to analyze top ethical concerns and develop approaches for heading off problems.
Gallagher said CHP's hospitals vary greatly in size, and so it has been important to recognize that organizational ethics approaches are not "one size fits all." Gallagher engages hospital-based teams in scaling and tailoring their own approaches, and this gives them ownership of the process. "It works well when they can create the change and be able to manage the change" to organizational ethics, he said.
Grounded in values
CHE, too, has given its hospitals leverage to tailor their organizational ethics approaches to local needs.
Boyle explained that CHE rolled out the concept of organizational ethics by gaining the buy-in of senior leaders at the system and its facilities first and then by providing ongoing education to people on ethics committees. The system trained these groups in the use of a process called values-based decision making, in which they take specific, intentional steps that help ensure they are using proper discernment when thinking about organizational issues. Armed with this knowledge, leaders at the system and hospital level form ad hoc committees to explore issues and concerns. For instance, one ad hoc committee deliberated the decision to move from defined benefit plans for employees to defined contribution plans.
CHE's Boyle said every hospital in the system now uses values-based decision making to arrive at organizational choices. He said CHE has gained such traction among its ministries by constantly making the case for the model and by ensuring leaders and ethicists especially are properly trained to carry out their role in the process.
Sticking with it
Bon Secours Health System of Marriottsville, Md., has a strategic plan for ethics, and it calls for an organizational ethics mind-set to be applied to major strategic moves, including partnerships, mergers and acquisitions. The plan also calls for the approach to be applied in human resources decisions impacting many people, like those regarding compensation.
John Wallenhorst, Bon Secours vice president of mission and ethics, said that in rolling out the model at the system level and at the local facilities, it was important to be consistent over time. "It's like any discipline — it takes focus and concentration to carry it out, and you have to go and do it every day. There's a temptation to take short cuts. So a challenge is to hold ourselves accountable."
CHA's Hamel said systems like St. Joseph, CHP, CHE and Bon Secours have gained momentum in implementing their organizational ethics programs because they have given the initiatives the resources they required and invested the necessary time to make them a success. "People in their organizations could see the changes taking place, and people want to build on what works.
"Success breeds success, and this has energized people to move forward with organizational ethics," Hamel said.
Far-reaching impact
The organizational ethics approach has the potential to touch virtually every aspect of a system's operations:
- Patient care, including patient rights, insurance coverage denials and futile care
- Human resources, including layoff decisions, salaries, hiring practices and union activity
- Community impact, including advertising, environmental responsibility, responsible purchasing and investing
- Strategic planning, including mergers, acquisitions and closures of facilities or services
Drawn in part from the work of Leonard J. Weber, former faculty member of the University of Detroit Mercy.
Copyright © 2011 by the Catholic Health Association
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