BY: GERARD F. HEELEY, STD
Reports of lapses in organizational integrity and ethical behavior are disturbing and point to the need for leaders committed to organizational integrity. In recent years, organizations have increased their attention to codes of compliance and compliance programs, but these programs focus on minimal requirements and are not a manifestation of integrity. Leaders must create integrity-based ethics programs, which direct corporate actions and goals and assist in shaping organizational relationships and decisions based on mission, vision, and core values.
Organizational leaders must hold values that may be in conflict in a balanced tension. Such conflicting values include the Hippocratic tradition and population-based healthcare, caring for patients and families and containing costs, and competition and collaboration.
Leaders can model integrity by addressing conflicting values overtly in decision-making processes.
Recent reports of lapses in organizational integrity and ethical behavior are disturbing. According to a survey on unethical and illegal behavior in American businesses, 48 percent of 1,324 randomly selected workers, managers, and executives in various industries admitted to unethical or illegal behavior.1
The respondents' reasons for committing unethical acts point to the need for leaders committed to organizational integrity and indicate areas for their attention. Triggers included poor leadership; poor internal communications; lack of management support; company politics; long work hours; heavy work loads; little or no recognition of achievements; pressure to meet sales, budget, or profit goals; insufficient resources; difficulty balancing work and family; and personal financial worries.
Fifty-seven percent said they felt more pressure to be unethical than they did five years ago; 40 percent reported that the pressure has intensified since 1996. Workers in manufacturing and healthcare reported the most pressure to act unethically or illegally. The unethical or illegal behaviors included cutting corners on quality, covering up mistakes, taking sick leave when not ill, deceiving customers, and pressuring others.
Leadership and Organizational Integrity
Organizational integrity consists of three elements: a reasonably coherent and relatively stable set of highly cherished values and principles; verbal behavior expressing these values and principles; and conduct consistent with these values and principles.2 The leader's words and deeds must be consistent with the organization's stated values and principles.3
In recent years, organizations have increased their attention to codes of compliance and compliance programs. Compliance programs are necessary for various reasons, but such programs are not a substitute for organizational integrity. Because their goal is to "prevent, detect, and punish legal violations"4 they tend to focus on meeting minimal legal and regulatory requirements.
Leaders committed to organizational integrity set a higher standard. They direct corporate actions and goals and assist in shaping relationships and decisions based on mission, vision, and core values. In addition, they define and give life to an organization's guiding values, create an environment that supports ethically sound behavior, and instill a sense of shared accountability among employees and all those associated with the organization.5 Integrity is achieved when an organization's actions are consistent with its character; the greater the consistency between the organization's character and actions, the greater the integrity.6
Value Tensions Leaders Face
The root of the word "integrity" means "to hold together." Leaders committed to integrity must demonstrate the ability "to hold together" — to balance — various, sometimes conflicting, values.7 Currently, healthcare leaders juggle several values that are the source of conflict.
Hippocratic Tradition and Population-Based Healthcare
The goal of the Hippocratic tradition, defined as the covenant between a physician and patient, is to maximize the health of the individual. The goal of population-based healthcare, however, is to maximize the health of the population.
Both the Hippocratic tradition and population-based healthcare are important to the delivery and reception of healthcare. The leader's responsibility is to uphold both values, encouraging providers to foster the caregiver-patient relationship while assuring the fair distribution of resources in the community.
Caring for Patients and Families and Containing Costs
Few healthcare leaders would argue that the value of patient care is at times in tension with the value of resource stewardship. (Delays in access and failure to disclose information are examples of serious breaches of care.) Several ethical considerations can help balance the two values.
First, rationing, a frequently used method to control expenditures, must be an explicit process with attention to ethical criteria. Charles Dougherty says that "rationing should:
- Be done in the context of universal coverage for basic care
- Serve the common good
- Protect those who are most vulnerable
- Guard such important intangibles as caring and trust
- Set priorities openly and avoid insidious discrimination
- Observe the Golden Rule, meaning those who ration must themselves be subject to rationing."8
Second, clinical practice should not be compromised for financial gain. Third, treatment allocation decisions will be based on evolving, and, at times, incomplete, clinical, scientific, and financial evidence. Fourth, high-quality care will be defined in terms of patient satisfaction, outcomes, and cost-benefit analysis.9
To lead with integrity is to delve into innovative processes and decision-making models that endorse both the care of patients and good stewardship.
Competition and Collaboration
Competition among hospitals has caused them to look inward to their needs, strengths, and competitive advantages and has resulted in healthcare organizations examining each other more than the communities they serve. But competition is also a value in healthcare. When it rewards those able to provide, at a lower price, services of a quality equal to or better than a competitor's, competition leads to greater efficiency. It forces healthcare organizations to state what value they add to a service and how they differ from the competition.
Collaboration by healthcare organizations for the good of the community may not be as recognizable a value as competition. But collaboration enhances the common good. When healthcare competitors join forces to address a community need, it proves a common commitment to do good and helps generate good will. For example, in Colorado patients, providers, purchasers, employers, and payors developed a code of ethics for managed care.
Value Tensions and Decision Making
A practical way leaders can model integrity is by addressing value tensions overtly in decision-making processes. A process may include:
- Naming the important values
- Sharing perceptions of how and why these values are in conflict, issues that the value tensions raise, and the expected outcomes if one value is favored over another
- Examining whether potential decisions and actions are consistent with the organization's character as defined by its mission, vision, and core values
- Projecting the effect any decision or action will have on the community's perception of and trust in the organization.
Addressing value tensions and involving other decision makers in the process widens the circle of those advancing integrity within the organization and increases leaders' effectiveness in shaping an ethical organization.
For more information, contact Dr. Heeley at 303-831-4880; e-mail: firstname.lastname@example.org.
- Del Jones, "Doing the Wrong Thing," USA Today, April 4, 1997, p. 1.
- Martin Benjamin, Splitting the Difference, University Press of Kansas, Lawrence, KS, 1990, p. 51.
- Benjamin, pp. 51-52.
- Lynn Sharp Paine, "Managing for Organizational Integrity," Ethical Issues in Business: A Philosophical Approach, Prentice Hall, Upper Saddle River, NJ, 1996, p. 495.
- Paine, p. 499.
- For a discussion of a compliance model that reflects the mission dimension of faith-based healthcare, see John F. Tuohey, "Covenant Model of Corporate Compliance," Health Progress, July-August 1998, pp. 70-75.
- Laura Nash, Good Intentions Aside, Harvard Business School Press, Boston, 1993, p. 3.
- Charles J. Dougherty, "How to Avoid Flying Blind," Health Progress, March-April 1997, p. 22.
- "Code of Ethics for Managed Care in Colorado Working Document," Rocky Mountain Center for Healthcare Ethics, April 1997.
Dr. Heeley is senior consultant, Rocky Mountain Center for Healthcare Ethics, Denver. This article is adapted from a lecture to the Maryland Hospital Association, June 3, 1997.
For more information on leading with integrity, see the Catholic Health Association's online resource Organizational Integrity in Catholic Healthcare: The Role of the Leader. To order a copy of the resource call CHA's Order Processing Department at 314-253-3458.
Copyright © 1998 by the Catholic Health Association of the United States
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