BY: BRIAN O'TOOLE, Ph.D.
Dr. O'Toole is vice president, mission and ethics, Sisters of Mercy Health System, St. Louis.
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Summary
Despite the relatively recent advent of organizational ethics committees — created to address operational concerns that are not always appropriate for a clinical ethics committee to take on — there remain impediments (such as time constraints, limited ethical expertise, lack of senior leaders at the table, and waning interest of members) to the impact such a group might have.
Committed to addressing operational concerns in a meaningful and "value-added" way, and mindful of the challenges that can limit the effectiveness of organizational ethics committees, the St. Louis-based Sisters of Mercy Health System developed an approach that has proven successful. Without changing the committee's goals — education, policy, and consultation — Mercy's renewed Corporate Ethics Committee was restructured to include ethical experts, people knowledgeable about particular issues, and people with authority.
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Although organizational ethics has received increased public attention, the concept has been used mostly to describe efforts to avoid wrongdoing and illegality (as well as the need to make such efforts). In Catholic health care, however, the term should have a much broader meaning. Critical strategic and operational decisions arise in which viable options require leaders to prioritize and choose from among competing values. "Organizational ethics" in Catholic health care means that decisions are made that do not conflict with — indeed, are most in keeping with — the organization's mission and values.
Many Catholic health care organizations have developed and use a type of formal decision-making process for significant strategic issues, particularly issues involving collaboration or the initiation or closing of a particular service line or health care facility. In this process, health care leaders use a stakeholder model of decision making to examine and weigh the impact of the proposed decision on all affected parties, including their own organizations.
Although this can be a helpful process, it is not normally used for specific operational decisions. Some issues — when and how to downsize, for example; how to conduct point-of-service payment collection and how much to collect; when and how to discuss medical errors with patients and families; or even broader matters, such as what constitutes "just compensation" for entry-level, lower-paid employees; and what are appropriate measures and requirements for diversity — are dealt with in Catholic health care facilities' normal operations. Formal decision-making processes rarely are used concerning them. But it is in observing how Catholic organizations decide such issues that employees and community members (rightly or wrongly) make their assessment whether Catholic health care is living up to its mission and values.
Organizational Ethics Committees
Hospital clinical ethics committees sometimes are asked — or, more often, volunteer — to address ethics issues in the realm of organizational operations. In my experience, however, such efforts usually meet with only limited success. Although the members of an organization's clinical ethics committee have some degree of competency in ethical decision making, they are likely to find that the ethics analysis involved in operational decision making is quite different. In addition, in most cases the members of the clinical ethics committee have an inadequate understanding of the operational complexities of organizational ethics issues, and, moreover, have no "skin in the game" — that is, no direct responsibility for helping the organization achieve its operational goals. Small wonder, then, that most health care leadership teams are not inclined to turn to clinical ethics committees for assistance in addressing operational ethics issues.
Because of this, some hospitals have developed actual organizational ethics committees. Designed to be structurally similarly to a clinical ethics committee, an organizational ethics committee usually comprises leaders drawn from a cross section of professional and operational roles, thereby ensuring a rich diversity of perspectives. Although these committee members tend to have a better understanding than a clinical ethics committee of operational ethics issues, their effectiveness, in my experience, is hampered by a number of factors.
Time constraints limit their ability to fully understand the complexities of particular operational issues and to develop ethics skills in analyzing those issues. In addition, membership rarely involves senior leaders. As a result, the committee must, first, jump all the usual hurdles to "sell" these recommendations and policies to senior leadership as a whole, and, second, spend a good deal of time and effort implementing those recommendations and policies. Absent a champion or a leader designated to ensure follow-up, such a committee will have a very limited impact, and, seeing that the group's impact is limited, the members will soon begin to reduce their involvement in it.
The Sisters of Mercy Approach
In light of these challenges and frustrations, and out of a commitment to address operational organizational ethics issues in a meaningful and "value-added" way, the Sisters of Mercy Health System, St. Louis, has developed a different approach that actually works. At Mercy, the approach is utilized at the system level, but it can be adjusted to be replicated on a local facility level as well.
In 1987, Mercy formed a Corporate Ethics Committee to address issues in organizational ethics. Its stated purpose was to "strengthen ethical decision-making corporately and institutionally across the Sisters of Mercy Health System." The committee, comprising a dozen or so persons representing a variety of leadership roles from throughout the system, understood its focus to be similar to that of a clinical ethics committee: education, policy, and consultation.
For a number of years, the committee sponsored educational programs in clinical ethics, with such topics as assisted suicide and withholding and withdrawing medical treatment; in business ethics, it focused on basic business ethics principles and issues such as providing access to care. The committee developed position papers and policies on, for example, joint ventures, care of AIDS patients, socially responsible investing, managed care, privacy and confidentiality in information services, downsizing, and employer-employee relations. Occasionally the committee was apprised of (and was asked to provide consultation on) specific system initiatives, such as social accountability and labor relations.
Our system benefited from having this type of organizational ethics committee structure and focus. By developing educational programs, position papers, and policies, the committee helped foster a more ethical climate within Mercy concerning the ways patients experienced caregiving, co-workers experienced their work life, and hospitals understood their responsibilities to their communities. In addition, the rich discussions that preceded and fostered these programs and papers were also "value-added" in and of themselves to the degree that participants returned to their leadership roles enlightened and energized by particular aspects of moral wisdom.
On the other hand, however, the limitations imposed by this type of structure and focus also became increasingly evident: Committee members did not always have adequate ethical expertise or (in a number of cases) a sufficiently thorough understanding of the particular organizational issue or topic being discussed; agenda items did not always have a formal link to, or timely involvement with, critical system or hospital-specific initiatives; and there was no structure or methodology to ensure accountability for implementation of positions or policies.
The Restructured Committee
To address these issues, in 2001 the system made three significant changes to restructure and refocus the Corporate Ethics Committee. The committee's goals remained the same, but the means to achieve those goals were strengthened.
Committee Membership
The traditional hospital ethics committee format was abandoned. The system's leaders recognized that, to address critical organizational issues effectively, the committee would require:
- People with strong ethical expertise
- People who knew a particular issue thoroughly
- People who had either the authority or the leverage to initiate and implement any needed change
To accomplish this, certain individuals possessing ethical expertise were identified as members of the Corporate Ethics Committee's core group; they would participate in every committee meeting. Membership in this core group would normally require a master's degree or doctorate in ethics. (If a facility, rather than a system, were to replicate this approach, it would probably not have such a requirement.) Currently the core group has seven members.
As a particular organizational ethical issue is identified either at a hospital or at a system level, the core group (in conjunction with Mercy leadership) identifies key leaders or clinicians who either have a thorough knowledge of the issue or who are in positions of leverage. These people are asked to meet with the core group, and the combined group then constitutes the full membership of the Corporate Ethics Committee for that particular issue.
Although the combined group can meet as often as needed, it should ideally aim to complete its work in one full-day meeting. After the group completes its task, it then disbands. When another ethical issue arises, the core group again meets with those identified as relevant key leaders or clinicians and all become full participating members of the committee for that particular issue. And the entire process then repeats itself.
Selection of Issues
The organizational ethical issues to be addressed by the committee are identified by the core group through communication with Mercy leadership. Each issue receives advance approval of the system's president/CEO or the appropriate leader in the area of the issue to be addressed.
This step is critical, for it ensures that the Corporate Ethics Committee is meeting a recognized need. In addition, the committee's makeup gives system leaders confidence that its work will be both morally justifiable and capable of being implemented in a practical way. As a result, the committee's work is viewed as integral and "value-added," rather than peripheral to the Mercy ministry.
Focused Effort
To the highest degree possible, every specific organizational ethical issue the committee addresses is defined narrowly and has an identified outcome that is to be achieved in a specific limited time frame. In addition, the committee is expected to recommend the process needed to implement — and measure the degree of implementation of — its recommended change.
If this process is to work, it is critical that the system's leaders — once they have accepted a recommendation by the committee — commit themselves to implementing the recommendation and hold the relevant leaders accountable for its implementation.
The redesigned committee addressed its first issue in 2001. The question was: How should Mercy implement what was then the new Joint Commission on Accreditation of Healthcare Organizations requirement that such organizations disclose unanticipated outcomes? At the request of the Corporate Ethics Committee's core group, Mercy's leaders agreed that the organization should have a systemwide approach to such disclosures, and one that would be respectful not only of the affected patients and their families but of the caregivers involved as well. In addition, all agreed that the organization should not be unnecessarily exposed to liability because of an inappropriate communication and, indeed, that there should be no communication without full knowledge of the facts.
To address this organizational ethics issue, Mercy's leaders assigned a representative group of clinicians, nurses, and risk managers, along with legal counsel, to meet with the committee's core group. All thereby became members of the Corporate Ethics Committee for that one particular issue. The committee was to develop a set of guidelines for communication about unanticipated outcomes that would be implemented systemwide.
The group met for a full day to discuss and create these guidelines. Some participants suggested guidelines that were morally laudatory but not practical. Some proposed guidelines were seen as practical but not fully in keeping with the organization's mission and values. In the end, because the committee represented a cross section of ethics experts and content experts, it was able to assure Mercy's leaders that the guidelines developed were both morally appropriate and capable of being implemented in a meaningful and practical way. The proposed guidelines were presented to and approved by the system's leadership. Risk management leaders were assigned the responsibility of ensuring the guidelines' implementation throughout the health system.
A Variety of Issues
In subsequent years, the Corporate Ethics Committee has addressed other issues. These include clinical issues, such as assessing specific drugs on the pharmacy formulary and developing indicators for required ethics consults; workforce issues, such as compensation for entry-level and low-level employees and hiring for "organizational fit"; and operational issues, such as guidelines concerning point-of-service payment collection, investment, and fund-raising. Some of these issues required only part of a committee meeting and were settled by the core group with the assistance of only a few "content experts." Other issues were more complex, either in the deliberation they required or in their implementation, and as a result required multiple meetings.
The Corporate Ethics Committee continues to meet three to four times a year to help address issues in organizational ethics. As I noted earlier, the restructured and refocused committee was not intended to serve as a "watchdog" or to ensure the avoidance of wrongdoing. Rather, complex issues in health care today require the careful weighing and balancing of competing values and goods. Mercy's Corporate Ethics Committee is designed to assist leaders responsible for doing this, so that the decisions made — and their implementation — are those most in keeping with the organization's mission and values.
Copyright © 2006 by the Catholic Health Association of the United States
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