Institutional Integrity: Values in Action

March-April 2002

BY: DIANE BISSON, PhD

Dr. Bisson was the director, Mission & Values, Providence Centre, Toronto, Ontario, Canada, for five years. She is currently a consultant.

Charles Dougherty has defined mission as "the forward thrust of the tradition" and tradition as our "collective memory."1 Tradition is the lens through which we know ourselves and one another. Dougherty maintains that a culture or an organization can, like an individual, develop Alzheimer's disease. When a culture loses its collective memory, it is confused in its own environment—it is unable to recognize others or itself. In effect, it loses its sense of identity, purpose, and mission.

For health care organizations, numerous factors can contribute to a sense of identity confusion. For Providence Centre, Toronto, Ontario, a long-term care and rehabilitation hospital and home for the aged, the factors are legion. Providence Centre struggles with increasing patient acuity as government policies encourage acute care hospitals to "download" patients as "efficiently" as possible. No increase in funding relieves this increased acuity, and many facilities face cutbacks of previously allocated funds. With smaller budgets for wages, long-term care facilities compete with acute-care facilities for an ever-shrinking employee pool. With fewer dollars, retention also becomes an issue. (One of our clinicians, for example, was recently lured to an acute-care facility in the same city to do a similar job for a $10,000 increase in salary.) In addition, increasing diversity among staff means that values held by a variety of different cultural and religious traditions must find congruence with the stated values of an organization. Such confusion can result in no clear sense of identity, thus compromising institutional integrity.

Personal integrity is often defined as consistency between what a person says and does. Institutional integrity is consistency between what an institution says it is (its mission statement and articulated core values) and how it behaves (how it puts the core values into action at both the individual and corporate level).

The core values of an institution name desired or preferred outcomes and are reflected in attitudes and behaviors.2 Behaviors are often assessed on a personal level: How do staff act toward the patients, residents, clients, families, and each other? How do managers treat their staff? Because an institution acts as a corporate body, assessing how behaviors (such as human resource practices, budgeting, and strategic planning) reflect the values is just as important.

This article seeks to outline one institution's approach to "grounding" itself in its core values in order to nourish institutional integrity. The basic assumption is that health care facilities nourish institutional integrity by putting their values into action. Because we can define "integrity" as wholeness or consistency, a first step in living with integrity is understanding what an organization's identity is. The next step is ensuring that corporate and individual behaviors reflect that identity.

A Clear Focus Based in Behaviors
If the first step to nourishing institutional integrity is having a clear sense of one's identity, the organization must begin with a relevant and current mission statement.

Mission How the mission statement is developed is as important as the statement itself. Christopher Bart has determined, first, that the quality of the mission statement process is strongly associated with hospital performance and, second, higher levels of participation by stakeholder groups contribute to better performance outcomes.3

In 1998 Providence Centre revised its mission statement using a process of redevelopment that involved the sponsors, board, and staff at all levels of the organization. Providence Centre worked on the assumption that a mission statement answers three questions:

  • What is our purpose for being?
  • Whom do we serve?
  • How do we carry out our purpose?

Poetic mission statements are of little value without a basis in the concrete. The focus, therefore, must be behaviorally based, with the board and staff explicitly understanding the behaviors and attitudes necessary to ensure fidelity to the mission at all levels of the organization. These behaviors and attitudes are the core values.

Core Values In 1995, Providence Centre discerned its six core values (sanctity of life, human dignity, compassionate service, community, social justice, and social responsibility). It then developed a "Values in Action" document that defined each value and the behaviors associated with the value Using the descriptions as a guide (see Box below), each Providence Centre department and program articulated how it put the values into action. Staff were encouraged to give concrete examples and to focus on their behaviors. Each program or department submitted responses on forms in chart format, with one form per value. Correlating each section of the description of the value, the program or department provided an example of a behavior that put the value into action. The responses from each area were compiled into a "Values in Action" book, which was then distributed to staff. This book was used for much of the Mission and Values education in subsequent years, including orientation, the Mission and Values Review, and ongoing education.

Processes
A vital component of putting values into action is ensuring that individual and organizational goals match, beginning with initial recruitment.4 Common goals help ensure institutional integrity. Health care organizations must have processes in place to ensure that facilities hire staff who understand the critical importance of putting values into action. To ensure continued understanding after recruitment, Providence Centre examines key moments in an employee's relationship with the organization (hiring, orientation, six-month probation, and performance reviews). We developed a reflection tool for each time point in which employees examine their lived commitment to the behaviors that make up our values.

Hiring Examining both technical competency and values compatibility are important when hiring staff because doing so helps ensure that an individual's values fit with those of the institution. As Br. Tom Maddix and Claudette Savard say, "It is easier to develop new skills than it is to change people's attitudes."5 Applicants at Providence Centre complete a 10-question Mission and Values Reflection questionnaire in which they rate themselves according to statements that reflect Providence Centre's core values. For example, the statement "I am compassionate with patients and residents" reflects Providence Centre's core value of compassionate service. The candidate rates himself or herself on a scale from 1 to 7 ("rarely" to "always") and provides an example for each statement. Because people tend to rate themselves highly, managers examine the quality of the example when making hiring decisions.

The Mission and Values Reflection tool fulfills several functions: It underlines for the candidate how important mission and values are to Providence Centre; it provides more information to the manager or team doing the hiring by helping them determine which candidates fit the organization; and it can provide a focus for interview questions. It has also had an unexpected benefit of determining candidates' literacy.

Orientation Orientation of new employees begins with an introduction to the history of Providence Centre and its founders, the Sisters of St. Joseph of Toronto. The director of Mission and Values introduces the organization's mission statement, core values, and vision, and the "Values in Action" document is used in a reflection process that examines behaviors expected by particular programs and departments. The mission and values component of the orientation concludes with a video program on diversity, which is a clearly reflected part of our core value of community.

Mission and Values Review After employees have been at Providence Centre for six months, the director of Mission and Values arranges an individual interview. To help prepare for the interview, employees complete another reflection tool on values that asks for an example of how they have put each of the values into action during the previous six months. The Mission and Values Review:

  • Reiterates the mission and values introduced at the orientation
  • Underlines the importance of the mission and values
  • Provides an opportunity for reflection in a busy work environment
  • Provides the director of Mission and Values with an opportunity to learn from employees and to see the institution from a fresh perspective regarding how best to put the mission and values into action

Performance Review Providence Centre's annual performance review form contains a section on mission and values. In this section, the employee chooses a value and commits to putting it in action in better ways during the next year. A recent evaluation of this section of the performance review, however, identified the fact that employees need assistance in completing this section—they found the question to be too vague. With the "Values in Action" document used as a standard, clarification of this section is currently under way.

Ongoing Education
Ongoing education is necessary to help staff reflect on the ways in which their work enables the organization to be faithful to the mission and values. In 1998, for example, a special program entitled "Mission Alive" was conducted. A series of sessions was held with each department, unit, and shift. By reflecting on their personal experiences, staff learn from and challenge each other. These half-hour sessions were facilitated by the director of Mission and Values. During the informal meetings, which were located in the participating units or departments, staff were able to discuss their struggles and successes in putting the values into action. They were comfortable providing comments that would be presented in a report to senior management because their contributions would remain anonymous.

Other educational tools used at Providence Centre to keep the mission and values in the consciousness of employees include:

  • A regular mission and values column in the Centre's newsletter
  • A mission and values poster displayed throughout the facility
  • A mission and values bulletin board outside the office of the director of Mission and Values
  • Staff awards based on behaviors reflected by the values
  • Annual Founder's Day celebration

Policies
Catholic social teaching and government legislation help Providence Centre ensure that policies for staff, volunteers, patients, residents, clients, and families are consistent with the values and nourish institutional integrity. The explicit connections are important. For example, we consider all Human Resources policies in the light of the core value of human dignity.

Institutional policies must reflect the values; employees should be treated with the same dignity, respect, and compassion that we expect them to extend to patients, residents, families, and each other. For example, a few years ago a department questioned whether we were treating employees with dignity when we "walked them to their cars" at termination. The members of this department thought the procedure was demeaning for someone whose employment was being terminated because of restructuring. They believed it indicated a lack of trust in the employee. Senior management discussed the policy, and it was then changed. Now only in exceptional circumstances (e.g., being fired for stealing) are people "walked to their car" by security or Human Resources staff after termination.

Ongoing Evaluation and Renewal
Ongoing evaluation and renewal are important to sustain institutional integrity. We can better integrate the commitment to the core values in our daily activity through reflection on experience.

Clarity Mission and values statements depend on context, so periodically testing for clarity is important.

Processes In the fall of 1999, we conducted a "Mission Resource Assessment" through individual interviews with managers. The goal was to determine the usefulness of the processes and resources used to help nourish institutional integrity. In response to the assessment, we developed an action plan to strengthen the processes.

Fidelity At the request of the CEO and board of directors in 1998, and again in 2000, we developed a report on fidelity to the values. We used documentation compiled for other purposes: staff, family, and patient/resident surveys; accreditation reports; results of a review by Catholic Charities of Toronto; and a values survey of patients, residents, clients, and their families. The information was compared with the "Values in Action" document, which names behaviors necessary to ensure fidelity.

Interesting observations emerged from this approach. For example, for the value of human dignity, Providence Centre has indicated that "meaningful participation decision making is encouraged and enabled through the provision of information and support." Yet when we compared the results of the satisfaction surveys, we found that staff felt Providence needed improvement in this area—the value of human dignity was not being put into action by the facility corporately as well as it could. Currently Providence is implementing council structures, which, we hope, will enable more effective participation of front-line staff in decision making. In the next round of surveys, we will evaluate whether staff satisfaction has increased in this area.

Nourishing institutional integrity in the midst of confusion requires strategy. Mintzberg points out that "strategy is a concept rooted in stability, not change. Organizations pursue strategies for purposes of consistency. But they sometimes need strategic change, too — they have to discard their established directions in response to a changed environment."6 The core values of an institution offer some stability in moving forward in an ever-changing environment.

Ultimately, of course, the extent to which a facility is successful in ensuring its values are put into action is measured in the quality of care that is extended to patients, residents, and clients and the extent to which employees are treated with dignity and compassion. This work nourishes institutional integrity—consistency between what an institution says it is and how it behaves. Statements on the wall mean little if the values of an institution are not visible in actions from the bedside to the boardroom.

NOTES

  1. Charles Dougherty, "Tradition, Mission, and the Market," Health Progress, July-August 1997, pp. 44-51.
  2. Paul C. Nystrom, "Organizational Cultures, Strategies, and Commitments in Health Care Organizations," Health Care Management Review, vol. 18, no. 1, Winter 1993, p. 43.
  3. Christopher K. Bart, "Mission Statements in Canadian Not-for-Profit Hospitals: Does Process Matter?" Health Care Management Review, 2000, vol. 25, no. 2, pp. 47, 58.
  4. Peter M. Ginter, Linda M. Swayne, W. Jack Duncan, Strategic Management of Health Care Organizations, 3rd. ed., Blackwell Publishers, Malden, MA, 1998, p. 345.
  5. Thomas D. Maddix and Claudette Savard, "Mission and Diversity: An Experience in Integration," Health Progress, January-February, 1999, p. 47.
  6. Henry Mintzberg, Bruce Ahlstrand, Joseph Lampel, Strategy Safari: A Guided Tour through the Wilds of Strategic Management, The Free Press, New York, 1998, p. 364.

Values In Action (1995)

Sanctity of Life: The worth of a person is not diminished by frailty, disability, or age. We support holistic approaches to health care. Suffering and death are part of the natural process of life. We identify and resolve moral issues in a responsible manner.

Human Dignity: Every person is respected and accepted. Privacy and confidentiality are respected in all relationships. The spiritual, religious, and cultural traditions of individuals are respected. Discrimination is not tolerated. Meaningful participation in decision making is encouraged and enabled through the provision of information and support. The insight and experience of staff are valued in management decisions.

Compassionate Service: Our first priority is the well-being of our patients and residents. The unity of the whole person is paramount in our care and service. Each person will show empathy and concern for others. The environment is stimulating, comforting, and conducive to individual fulfillment.

Community: Our work is strengthened through collaborative decision making, cooperation, and mutual support. Information is provided to all who live and work at Providence in a timely, open, and honest manner. We strive to work in partnership with others to provide the optimal service for the elderly within the resources available to us.

Social Justice: We strive to identify and respond to those in greatest need. Our decisions reflect our concern for the well-being of the poor, the disadvantaged, and the elderly. Fair and humane mediating structures are accessible to all for use in resolving conflicts.

Social Responsibility: We are accountable for, and endeavor to use, the resources entrusted to us in a responsible manner. Planning is an interactive and dynamic process identifying the pursuit and application of contemporary knowledge. We believe in the dignity of work and support personal growth and fulfillment. We are committed to preserving the environment.

 

Copyright © 2002 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.