BY: PAUL D. MARCEAU, ThD
Dr. Marceau is vice president, mission services and ethics, Trinity Health,
Novi, MI.
The Process Renders Decision Making More Participatory and Transparent
and Produces Better Decisions, Too
Mission discernment (also known as ethical discernment or ethical decision
making) is emerging as one of the more encouraging recent developments in U.S.
health care. Health care organizations have not only chosen a variety of names
for the process, they have also introduced it into their structures and operations
in varying ways. The common focus, however, is on responsible decision making
in light of the organization's mission and values.
Experience in operations and at the corporate level with two Catholic health
care organizations (Holy Cross Health, South Bend, IN, and Trinity Health, Novi,
MI) has provided me with the opportunity to experience the challenges and possibilities
of this process—and to have learned some lessons along the way.
Mission Discernment
Mission discernment is concerned with what an organization might do.
It provides a tool that an organization can use to evaluate its major initiatives:
adding or dropping a service line, for example, or divesting itself of a facility,
entering into a joint venture, or merging with or acquiring another organization.
(Analyzing existing programs, processes, or policies in light of the
organization's mission and values is, on the other hand, usually described as
mission assessment. The purpose of a mission assessment is to discover
whether, and to what extent, an organization's current operations are aligning
with, achieving, or advancing its mission.)
Mission discernment, however, remains a work in progress. Organizations vary
greatly in the ways they integrate the process into their decision-making matrix.
Naturally, this leads to a variety of expectations concerning what mission discernment
should be. That array of expectations also programs the subsequent satisfaction
or disappointment with the mission discernment process.
Mission discernment is important to some people because it adds a new, focused,
and clearly defined process to an organization's decision-making structure.
Others value it as a means of integrating mission/ethical analysis into an organization's
decision-making structures as a seamless part of its normal management, planning
and, marketing—not something apart from or parallel to them. And, of course,
still others contend that mission discernment should do both things. But no
matter how discernment is structured along this continuum, it will be buffeted
by crosswinds and conflicts.
Dilemmas of Mission Discernment
Mission discernment tends to face certain predictable dilemmas, each of which
can be illustrated by a catch phrase.
"Mission Trumps All" In the recent past, mission leaders argued strongly
to be given their rightful place "at the table" with other senior health care
leaders. Mission leaders wanted to be decision makers—like the leaders of legal,
financial, human resources, planning, and marketing departments—and no longer
relegated (as leaders of pastoral care departments are sometimes relegated)
to a subsidiary role in the organization.
Often, mission leaders' unspoken assumption was that mission should be (in
language borrowed from Rome) primus inter pares, first among equals.
Mission was sometimes referred to as "the conscience of the organization" (as
if no one else in the organization had a conscience, or had mission and values
in mind). Making mission primus inter pares could, however, put it "above
and beyond" the rest of the organization—and, in effect, segregate mission from
the organization's other operations. Mission leaders would then be at the table
with the other players, but still potentially isolated in a world of their own.
Mission would come to see itself, and especially the mission discernment process,
as a trump card, trumping all other considerations, financial, marketing, or
legal.
Of course, mission discernment should be seen as a clearly focused and defined
process, a process conducted by an identifiable group of people. But neither
the people nor the process can be detached from the ordinary decision-making
processes of the organization. If the mission discernment becomes too far removed
from the organization's ordinary decision-making processes, it can appear to
be a parallel process, monitoring and judging the decision makers. When this
happens, mission discernment assumes the role of moral watchdog over the organization's
other functions—and the mission-discernment team is seen as a kind of independent
review board. Those participating in mission discernment may come to see themselves
as guardians and protectors of the organization's values, giving mission's "thumbs
up" or "thumbs down" to a project. Mission discernment then runs the risk of
irrelevance, becoming too detached from the ordinary decision-making processes.
"But It's All Mission" Another perspective is that all of the organization's
departments—legal, financial, clinical services, and the others—are about mission
too, that mission is the monopoly of no single department or person. No one
has a monopoly on mission, and all have a responsibility for it. Integrating
mission and values seamlessly into culture and operations is a goal for most
faith-based organizations. Values become habits; habits become culture. The
ideal of that model is that the values become completely integrated into the
culture of the organization. The danger is that they might become so integrated
as to become invisible, indistinguishable from good financial, legal, clinical,
and other practice.
But if mission is not identifiable and doesn't have clearly articulated "markers"
in these other professional areas, how can we know that we are doing it? The
challenge is to identify and articulate the issues and concerns of mission and
values as they aüe woven into the discussion of legal, finance, human resources,
and other functions. Mission discernment must, early in the process, identify
the questions in marketing, finance, and other functions that are value-laden
and may have implications for mission.
If these questions are not clearly identified and addressed, the mission leader
may be left with the task of going back and doing a "retrospective" mission
discernment, claiming that the mission issues were implicitly addressed all
along in discussions of finance and other functions. This will appear to the
audience reading the report as a search-and-justify operation. A "retrospective"
mission discernment is usually viewed with mistrust (no matter how accurate
it may be). Worse, it may be seen as a decision already made (usually as the
result of financial constraints) and then "baptized" with mission language.
As such, it will lack much credibility.
"Trust Us" Usually matters that are very confidential or sensitive
for an organization (e.g., the sale of a long-term care facility, the elimination
of a service line, or the outsourcing of a department such as laundry) are discussed
and decided by only a few—the organization's board and senior managers—without
consulting the rest of the "community of concern."*
* The phrase is John W. Glaser's. See his article, "The
Community of Concern" (Health Progress, March-April 2002, pp. 17-20).
When such a decision is announced, those who were not included in the decision-making
process may ask, "Was a mission discernment done, and, if so, who did it?" The
reply is usually: "Yes, mission and values issues were central to our discussions
from the beginning, and we did the discernment ourselves." But, unless the decision
makers have followed a clearly defined process and come up with a clearly identifiable
product, skeptics may wonder how the analysis of mission and values was done.
If there was no clearly defined process and no mission discernment report to
accompany the business plan, then accepting that plan becomes a matter of faith
and trust in the leadership and its integrity. And even if excluded stakeholders
trust and have confidence in the organization's leaders, they will feel no less
"out of the loop" concerning the decision made.
"But There Is No Alternative" Dedicated workers and managers of a financially
strained facility will struggle with enormous challenges to keep the mission
alive for the people in need of their care. The downside of such dedication
is that it may mean hanging on until it is too late and no option remains but
to close the facility or discontinue one of its lines of service. Then the response
from those who made the effort to keep the doors open is often: "It was simply
a financial decision" (which doesn't mean it wasn't also a responsible mission/stewardship
decision, painful though it may have been for the stakeholders directly affected
by it). Senior managers never want to make such a decision, but may be faced
with inevitable financial realities.
What possible good would a mission discernment do in this situation? Selling
or closing is inevitable; the decision has already been made. Why do a mission
discernment? It would be dishonest to pretend that the decision was based on
factors other than finance.
Although mission leaders generally loathe being confronted with this situation,
they might find it useful to conduct some form of mission discernment anyway.
The question then becomes: Given the fact that we cannot keep the doors open,
how can we best handle the transition? Who is going to be affected (patients?
employees?), and how do we assist them in the transition? Who is the buyer in
this divestiture, and what is the buyer's reputation? What values/criteria do
we establish in order to select a buyer? How do we choose well? In some ways,
given the situation, mission discernment is all the more important when only
a few options remain open to the organization. A painful situation needs to
be handled sensitively and well. The care of patients and employees in transition
is critical.
Lessons To Be Learned
Six lessons can be learned from such dilemmas.
- Leaders should keep the discernment process distinct enough from the decision
making as to be identifiable but not so separate as to be irrelevant to it.
- When leaders are considering a new initiative, they should early on decide
whether it qualifies for a mission discernment. Mission discernment should
not be the last step in a major initiative; nor should it be done "retrospectively"
on a decision already made. Mission discernment should not be seen as simply
the moral "Good Housekeeping Seal of Approval" of a decision already taken
on other grounds.
- Leaders should clearly identify those who will participate in the mission-discernment
process. They should appoint an identifiable leader or facilitator who will
be the lead in the process. The group processing the mission discernment should,
on one hand, include some decision makers (or staff members able to provide
valuable information or perspective) and, on the other hand, be sufficiently
broad-based to have access to the information and opinions (from, e.g., finance,
legal, and human resources) necessary for an informed decision. (One mission
discernment in which I was recently involved had more than 100 participants,
including employees, volunteers, and community members.) The nature of the
project will determine the extent of the involvement needed.
- In discussing an initiative, leaders should clearly identify the issues
of mission and values. These will often be found in the proposal's details
and will tend to be articulated in legal or financial—not mission—terms. Whether
the initiative involved is a strategic plan, a budget, or a benefits package,
it will inevitably be value-laden. Identifying the operative—but often unexpressed—values
is the task of a mission discernment group. This identification can be done
in one of two ways:
- With a discernment instrument or tool (either developed in the organization
or acquired by it) that articulates questions or areas of concern.
- As a result of conversation with stakeholders. Even organizations that
employ a mission-discernment instrument find that the most practical and important
issues often arise in focus group discussions (or even from demographic studies).
Hospital leaders I know were surprised to learn of the presence of a large deaf
community in a neighborhood they were considering for physician offices and
a clinic. They accordingly adjusted their plans to provide special services
that would address the needs of that population.
- Rely on the participants. Most people invited to participate in a mission-discernment
process are delighted with the opportunity. They are honored to learn that
they are the bearers of the organization's values and that their perspective
and opinion are valued. Those who are involved in operations may possess insights
and questions that have escaped the attention of managers and executives.
- Clearly communicate the values operative in whatever decision or choice
is arrived at. More than once I have heard leaders say, "We made the right
choice and for the right reason. But our communications with the stakeholders
were poor and we met with a lot of opposition or mistrust." Not many decisions
will meet with unanimous approval; members of the organization understand
that. What they want to know is why that particular course of action
was taken. What justifies it? What end or need does it serve? What values
does it advance?
People understand that priorities must be established, especially in cases
that involve competing values. Why, they ask, was this value (stewardship of
resources, for instance) chosen over that (compassion, say) in these particular
circumstances? People understand a decision better if they can see the mission
and values that were operative in the decision-making process. They are, by
the same token, suspicious of a business decision that is "baptized" in mission
language.
Understanding and Commitment
Those who have used an ethical-discernment process will remember the awkwardness
that often accompanied the process's introduction into the organization. They
will recall that co-workers did not recognize the process's terminology and
did not feel competent to do what was being asked of them. But the whole premise
of such discernments is that the people in our organizations do have
the professional skills, knowledge, and competencies, as well as the values,
to provide a critical analysis of a proposed initiative from a mission perspective.
They learn to trust both the process and their own contributions to it. And,
through the process, they discover the meaning and value of their own work and
its place in the organization's mission.
Copyright © 2003 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.