© Murat Inan / EyeEm / Getty Images Case Study Leadership for Health Professionals: Theory, Skills, and Applications Third Edition Gerald R. Ledlow E3. The position of CEO at this health system was the second turnaround opportunity that I accepted. I had a reputation for being a turnaround artist for health systems. At the point I arrived, this health system was about $500,000 in the negative net income column. And if things hadn’t changed, they probably would have ended the fiscal year with $2 million in the red. So, after my first 2 years as CEO, we were still working to turn this health system in a financially positive direction, even though we were having a positive net income for each year. However, the national health system with which I was associated was getting somewhat impatient and asked me to come to Chicago for a meeting. So I went to Chicago and met with them in a hotel suite. They advised me that they were going to sell the health system. I certainly was very upset with them. I asked them, “Why did you bring me from my last executive position—which was a very good position—and not even give me a time schedule with enough time to turn this financial situation around?” I told them that we were making significant progress toward changing not only our entire financial situation, but also toward gaining market share in a market that we already led, and I needed another year or two. It was a very good argument, and they agreed not to sell the health system. However, they came up with another request. They asked me to develop a strategy to take my main hospital rival out of operation and to drive them to close down. They said they would give me 2 years to accomplish this directive. I told them I would not accept this directive, because I did not think that having a strategic goal of shutting down another healthcare institution was ethically correct. It wasn’t right for their employees, and it wasn’t right for the community or patients who preferred their health system. Right then and there I told them that I would not accept that directive. I also told them that if they wanted to fire me they should fire me today because I refused to accept their directive. Interestingly enough, they decided not to fire me, and they abandoned their strategy to shut down our rival health system. As it turns out, I was with this health system for 11 years, and during that time, I went through three national system presidents. Just a few years after this incident, a new national system president was hired, and he also asked me to come to a national meeting in Chicago. He gave me the same directive—to take my chief rival healthcare competitor out of business. I was so surprised that I actually laughed! I told the new president, “You are the second national system president who has asked me to take out my chief health system rival, and I’m going to tell you the same thing I told the last one, which is that I don’t think it’s ethical. I’m not sure it’s even possible, and I’m not going to use my energy pursuing this dumb strategy. Therefore, if that’s your expectation for me, then you need to fire me today because I’m not going to accept it. I didn’t accept it several years ago, and I’m not going to accept it today. What I will accept is the strategic strategy to increase our market value.” Well, that national system president also backed down, and we never had another discussion about this strategy again. Content Link: Ledlow & Stephens, Leadership for Health Professionals: Theory, Skills, and Applications, 3rd Edition, Jones & Bartlett Learning, 2017 Chapter 6: Leadership Competence Chapter 10: Ethics in Health Leadership Copyright © 2018 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 2   ❚ Case Study Name: Date: Section: E3. Case Study Questions 1. If you were the CEO, would you have attempted to take your chief rival out of operation? 2. What professional and ethical questions would you have if you were to implement such a strategy? 3. What would be the ramifications for the community if you were successful in executing such a strategy? Copyright © 2018 by Jones & Bartlett Learning, LLC, an Ascend Learning Company Chapter 6 Leadership Competence II: Application of Skills, Tools, and Abilities “Thinking always ahead, thinking always of trying to do more, brings a state of mind in which nothing seems impossible.” Henry Ford Learning Objectives • Describe planning, decision making, and training in health organizations and provide examples of each. • Summarize the planning process and the decisionmaking process within the context of leadership. • Apply and relate at least two different decisionmaking models to a leadership situation. • Differentiate the levels or components of the planning process and distinguish each level or component from the others. Learning Objectives, cont. • Plan and design a quality improvement program based on a system of rational decision making for a health organization. • Compare and contrast willful choice to garbage can models of decision making, training leaders to training staff, and cultural competence to ethics and morality. Planning • Planning is an essential leadership skill that requires knowledge about planning and the ability to structure and develop a system of planning. • Health leaders who can understand, apply, and evaluate planning will have advantages over those who haphazardly plan or fail to plan. Planning, cont. • Planning occurs formally, informally, strategically (how the organization can best serve its purpose in the external environment), and operationally (how can the internal capabilities and resources of an organization be used effectively, efficiently, and efficaciously to achieve the strategies and goals of the organization as documented in the strategic plan). Planning, cont. • Planning is a process that uses macro- and micro-environmental factors and internal information to engage stakeholders to create a framework, template, and outline for section, branch, or organizational success; planning can be strategic, operational, or a combination of both Strategic Planning • Strategic planning is concerned with finding the best future for your organization and determining how the organization will evolve to realize that future. – It is a stream of organizational decisions focused in a specific direction based on organizational values, strategies, and goals. – The focus is on external considerations and how the organization can best serve the external markets’ expectations, demands, and needs. Operational Planning • Operational planning is about finding the best methods, systems, and processes to accomplish the mission/purpose, strategies, goals, and objectives of the organization in the most effective, efficient, and efficacious way possible. – The focus in operational planning concerns more internal resources, systems, processes, methods, and considerations. Planning, cont. • Planning is a journey. The journey must have a destination; this journey must be planned. It is a planned journey forward in time. In that light, planning includes both a process (achieving goals and objectives) and an outcome (the plan). • The ultimate outcome of planning is a vision that is achieved. – The desired future state is the vision of the organization. The vision is what the combined staff of the organization strives to achieve. Planning, cont. • The strategic plan is a roadmap, the organizational vision is the final destination, describing where the organization is going. • The healthcare leader must energize followers to buy in to the vision in order for the organization to begin its strategic journey. – Vision must be tested and retested to ensure buy-in from all stakeholders, including external and internal. Situational Assessment and Environmental Scanning • Situational assessment and continuous environmental scanning are crucial for organizations to survive in the dynamic health industry. • A health organization must understand the impact of the operating environment. The leader’s responsibility is to remain current and recognize situational and environmental changes that can impact the organization. Situational Assessment and Environmental Scanning, cont. • Forces that contribute to the health industry’s rapid and dynamic environment are varied but are cumulative and thus, have a cumulative impact on the industry. Macro-Environmental Forces • Legal (regulatory, executive orders, case law, etc.) and ethical forces • Political (including government policy) forces • Cultural and sociological (including values [beliefs and attitudes]) forces • Public expectations (including community, interest groups, and media) • Economic forces • Ecological forces Healthcare Environmental Forces [also called Micro-Environmental Forces] • Planning and public policy (regulation, licensure, and accreditation) forces • Competitive forces • Healthcare financing (third-party payers, public and private, and financial risk) • Technology (equipment, material, and supply entities) forces • Health research and education • Health status & health promotion (wellness and disease) • [Integration with other health disciplines] Public health (sanitation, environmental protection, etc.) forces Rand Corporation • The Rand Corporation suggests that the immense pressure of cost-containment efforts and speed of change are the leading factors influencing the health industry at this time. Multiple forces cumulatively contribute to change in the health industry. – Brook, R. H. (1998). Retrieved from http://www.rand.org/cgibin/health/showab.cgi?key=1998_77&year=1998 on May 11, 2009. Application of Skills, Tools, & Abilities • The dynamic whirlwind, often called “white water change,” frames a picture of the world the health leader must navigate. • Health leaders must continue to use the dynamic nature of the industry to challenge their organizations, groups, teams, and individuals to become more efficient, effective, and efficacious while under significant costcontainment pressure. Kotter • Kotter suggests eight steps to transform organizations in dynamic situations: 1. Establish a sense of urgency by examining market and competitive realities and identifying and discussing crises, potential crises, or major opportunities. 2. Form a powerful guiding coalition by assembling a group with enough power to lead the change effect [from any level of the organization] and encourage the group to work together as a team. Kotter, cont. 3. Create a vision to help direct the change effort and develop strategies for achieving that vision. 4. Communicate the vision by using every vehicle possible to communicate the new vision and strategies and by teaching new behaviors by the example of the guiding coalition [at lower levels of the organization, the leader translates the senior leadership’s vision for his or her section, branch, or unit into understandable and actionable tasks for that level and situation]. Kotter, cont. 5. Empower others to act on the vision by getting rid of obstacles to change, changing systems or structures that seriously undermine the vision, and encouraging risk taking and nontraditional ideas, activities, and actions. 6. Plan for and create short-term wins by planning for visible performance improvements, creating those improvements, and recognizing and rewarding employees involved in improvements. Kotter, cont. 7. Consolidate improvements and producing still more change by using increased credibility to change systems, structures, and policies that don’t fit the vision; hiring, promoting, and developing employees who can implement the vision; and reinvigorating the process with new projects, themes, and change agents. Kotter, cont. 8. Institutionalize new approaches by articulating the connections between the new behaviors and corporate [organizational] success and developing the means to ensure leadership development and succession. Changes in Environment • Leaders of health organizations should consider the changes in the macro- and micro-environment against the cost, quality, and access constructs for the community members they serve. – Also need to understand changes to the health organization concerning: • • • • • Operations Workforce Supply chain Revenue management/reimbursement Community health status The Leader’s Role in Planning • People look for leaders who have a vision and someone who can direct them in the path of the mission. • Planning is the fundamental function of leadership from which all other outcomes are achieved. • The first step in planning is establishing the organizational situational assessment; then the vision, mission, strategies, goals, objectives, and action steps are developed. The Leader’s Role in Planning, cont. • The vision provides the motivational guidance for the organization, and typically is defined and promoted by senior leadership. • Vision is how the organization intends to achieve its goals while “mission” defines why the organization pursues the goals it does. • Both vision and mission are “directional strategies.” • The mission statement is the organization's reason for being, its purpose. Goals • From the mission, strategies to achieve the mission and ultimately, the vision, are devised. • Goals are broad statements of direction that come from strategies. This multilevel approach focuses and narrows effort for each section within the health organization. – Goals further refine the strategies focused on the mission. They are expected to be general, observable, challenging, and untimed. Goals are general in nature; objectives are highly specific. Objectives • Objectives, in pursuit of achieving goals, are very specific. – SMART objectives must be “specific, measurable, attainable, rewarding, and timed.” • Action steps or tactics represent a fifth level of planning and provide the most specific approach for describing who, what, when, where, and how activities will take place to accomplish an objective. Health Leaders • Planning can be described as an ongoing process of thinking and implementing at multiple levels. • At each level, health leaders are directing, staffing, organizing, and controlling. • Health leaders must remember that “what is measured gets done”; all planning objectives and action steps must be measurable, assigned to an accountable and responsible person, and be set within a time period. Health Leaders, cont. • Periodic progress reviews, monthly or quarterly, are essential to see the movement toward success. – In this effort of directing, staffing, organization, and controlling, rewarding is also important. The five elements are crucial as leaders embrace the foundations and functions of planning. – Health leaders must publicly praise success and reward those who have achieved predetermined action steps, objectives, and goals. Decision Making and Decision Alignment • Decision making occurs in all organizations. Health organizations are faced with many decisions each day. • The decision-making process begins with identifying a question, problem, an area needing improvement, or an operational issue. • Problems, issues, questions, and operational challenges come to leaders and managers from many different people, both within and outside the health organization. Decision Making and Decision Alignment, cont. • Leaders and managers usually are taught to utilize the rational decision-making model using analytical (quantitative) methods and when necessary, coupled with group methods (qualitative) such as normative group technique (brainstorming, alternative categorization, prioritizing alternatives, and selecting an alternative based on group consensus) to triangulate (using both quantitative and qualitative methods) results and identify an effective decision. Decision Making and Decision Alignment, cont. • In truth, decision making is not as sterile and ordered as most have been taught. • Willful choice or rational decision-making models together with reality-based, or “garbage can,” models are used in organizations along with a myriad of tools and techniques. • The major domains of decision making are: – Willful choice or rational models – Reality-based or garbage can models – Combinations of willful choice and reality-based models Methods of Decision Making • Quantitative methods: Use tools such as multiple attribute value, probability-based decision trees, analytical mathematical models, linear programming, and similar tools. • Qualitative methods: Use tools such as focus groups, interviews (formal and informal), normative group techniques, and similar tools. • Triangulation methods: Combine quantitative and qualitative methods where, classically, qualitative methods are “theory building” and quantitative methods are “theory testing, validating, or confirming.” Decision Making • Bounded rationality in decision making – Decision making must occur within the bounded rationality of the environmental context in which the problem must be solved. • Willful choice decision-making models – Decision-making models and current understanding imply that decisions are made by rational, intentional, and willful choice. Willful Choice Decision-Making Models • Choice is guided by four basic principles: 1. Unambiguous (you know what questions to ask) knowledge of alternatives 2. Probability and knowledge of consequences 3. A rational and consistent priority system for alternative ordering 4. Heuristics or decision rules to choose an alternative Willful Choice Decision-Making Models, cont. • Six-step model of decision making applies willful choice model as follows: 1. 2. 3. 4. 5. 6. Identify the problem. Collect data. List all possible solutions. Test possible solutions. Select the best course of action. Implement the solution based on the decision made. Willful Choice Decision-Making Models, cont. • The practical six-step model assumes time and information are abundant, energy is available, and goal congruence of participants (everyone is focused on the same set of goals) has been achieved. Criticism of Willful Choice Models • Well-known leadership and management concepts consider preplanning (short- and long-term) as the method to solve ambiguity (not knowing what to do) in business, but as task complexity increases and time availability decreases, the ability to plan and problem solve increasingly becomes more difficult. • The rapid pace of operations and change in health today make traditionally based organizations less adaptive and flexible in complex environments. Criticism of Willful Choice Models, cont. • Information and time are assumed to be abundant and relatively free resources in rational and willful choice models; additionally, organizational participants in the decisionmaking process are assumed to have similar (if not the same) goals. • These issues are the basis of willful choice model criticisms. Criticism of Willful Choice Models, cont. • Reality of healthcare industry suggests that preferences of participants in the decisionmaking process often vary in illogical and emotionally dependent ways. Although considered in the willful choice models, time and information are not considered as valuable or scarce as reality actually suggests. Reality-Based Decision Making: Overview of the Garbage Can Model • Reality-based models, such as the garbage can model, are intended to extend the understanding of organizational decision making by emphasizing a temporal context (the situation at one point in time) and accepting chaos as reality. • Rational (willful choice) decision-making models are a subset of reality-based models. Reality-Based Decision Making: Overview of the Garbage Can Model, cont. • In ambiguous (do not know what to ask or do) situations where time and information are limited or constrained and “perfect information” impossible to acquire, where organization structure/hierarchy is loosely coupled, and organized anarchy (chaos) seems to embody the organizational persona, analytical decisionmaking models do not fit reality. Garbage Can Model Concepts • Garbage can models are attempts at finding logic and order in the midst of decisionmaking chaos. – Garbage, defined as sets of problems, solutions, energy, and participants, is dumped into a can as it is produced (streams of “garbage” in time); when the can is full, a decision is made and removed from the scenario. Garbage Can Model Concepts, cont. • Many things seem to be happening at once, technologies are changing and poorly understood; alliances, preferences, and perceptions are changing; solutions, opportunities, ideas, people, and outcomes are mixed together in ways that make interpretation uncertain and leave connections unclear. Decision Making • In management arenas, decision-making load, speed required in decision making, uncertainty, and equivocality (also known as ambiguity: not knowing what questions to ask or what to do) are commonplace. • The temporal nature of decision-making processes, if taken as “snapshots” in time, would show sequential arrival of problems, solutions, and information in a complex mix of participants, environmental factors, and consequences of prior decisions as reality in the “organized chaos” of decision making in organizations. Loose Coupling • Since time is not static and multidimensionality is reality, the garbage can model depicts the chaotic nature of decision making. • Loose coupling in organizations fosters a garbage can decision making approach. Loose Coupling, cont. • Loose coupling in an organization is defined as a more informal, differentiated focus; members of organization focus less on following the rules but still have structured connectivity of intraorganizational entities. – Loose coupling tends to allow a more flexible organization. Organizations that are loosely coupled, in the traditional sense, are more adaptive to change and environmental factors. – The strength of feedback loops determines organizational coupling: Stronger feedback loops imply tighter coupling, whereas weaker loops suggest loose coupling. Loose Coupling, cont. • Four criteria for determining coupling status in organizations are: 1. Formal rules where the closer the rules are followed, the more tightly coupled the organization (In entrepreneurial organizations, formal rules are not as important.) 2. Agreement on rules where the greater the employee congruence, the tighter the coupling (Entrepreneurial firms agree on social norms rather than formal rules.) Loose Coupling, cont. 3. Feedback where the closer the feedback in time, the tighter the coupling 4. Attention where empowered individuals allocate energy and time to prioritized projects in their area (Participation, competence, and empowerment foster focused attention to areas of responsibility.) Loose Coupling, cont. • In the garbage can model, the concept of loose coupling is required to understand decision making. As a thinking exercise, consider where a health leader should establish the level of coupling in a health organization; see figure on next slide. “The process is thoroughly and generally sensitive to load. An increase in the number of problems, relative to the energy available to work on them, makes problems less likely to be solved, decision makers more likely to shift from one arena to another more frequently, and choices longer to make and less likely to resolve problems.” - March, James G. & Weisinger-Baylon, R. (1986). Ambiguity and Command: Organizational Perspectives on Military Decision Making. Marshfield, MA: Pitman Publishing; p. 18. • Individuals in the decision-making process, directly and indirectly, are interconnected and influence the context of the decision at hand. Garbage Can Model • Decision possibilities in the garbage can form a spectrum from willful choice models to garbage can−based models. – Decisions by “flight,” “resolution,” and “oversight” are prominent categories in the model. • Flight is defined as a decision maker’s intentional movement (attention shift) to another area of concern (problem). • Resolution is defined as a decision that uses classical decision-making processes such as willful choice models. Garbage Can Model, cont. • Oversight is defined as decision makers activating a process or procedure before a problem becomes apparent, such as developing a standing operating procedure or using an established and documented process. • Much of the research shows that flight was a significant result of many decision-making processes. Optimization of Decision Making • Leaders in health organizations must develop a system of decision making while understanding that decision making is not always orderly by: – Evaluating the situation and decisions that need to be made across the organization (or within your area of responsibility) and categorizing decisions by quantity, urgency, information needed to make the decision, and variance in decision outcomes – Developing readily available information concerning core business functions Optimization of Decision Making, cont. • Standardizing, documenting, and training team members on decisions that need to be made routinely, where the same or similar decision outcome is required, and “pushing” those decisions to the lowest levels of the organization but requiring feedback loops • Determining decision-making load (quantity in a set time frame) and information available to make decisions (those not standardized) Optimization of Decision Making, cont. • Determining the importance of a decision to the organization by creating a system of risk determination, urgency, and technological requirements for nonstandardized decisions • Training team members on the decisionmaking system and processes Optimization of Decision Making, cont. • When a decision or decisions need to be made, a health organization leader must: – Evaluate the priority and risk of the decision to be made and determine if this is a standardized decision or a decision that needs to be worked through. – Evaluate time available, resources available, participant attention, goals, and incentives. Optimization of Decision Making, cont. • When a decision or decisions need to be made, a health organization leader must (cont.): – Determine which decision-making method to use: oversight based on established documented processes such as standing operating procedures, resolution using a willful choice model, or by pushing the decision to the appropriate level, individual, or group. It is also important to know when to make a decision (flight) based on the importance and risk level of the decision at hand. Optimization of Decision Making, cont. • To develop a reality-based decision-making system, a leader and manager must understand that decision making is not a sterile and orderly process in most cases. • Importantly, organizational decision making should be aligned (decisions should be in accordance with) the organization’s mission and vision statements and strategic planning−based goals and objectives. Tools of Decision Making • Quantitative methods include mathematical and computational analytical models to help leaders understand the decision-making situation (data turned into information and then into knowledge) and produce mathematical outcomes of solutions. – Some models are rather simple while others can be very complex. (Quantitative models assist in putting a “number” to uncertainty.) Tools of Decision Making, cont. • Models include multiple-attribute value and multiple-utility methods, linear programming, probability, and decision trees based on Bayes’ theorem, and can be as complex as discrete and dynamic simulation. Tools of Decision Making, cont. • Qualitative methods include a variety of tools, from personal intuition, discussions with team members, informal interviews, formal interviews, focus groups, nominal group techniques, and even voting. – Qualitative methods are very useful since experience, intuition, and common sense are used to aid decision making by individuals as well as groups. Triangulation • Triangulation is a more thorough method to make decisions. Although triangulation takes time, it brings both quantitative and qualitative approaches into the decision-making process. – It is common for a group to use nominal group techniques to come to a small set of possible solutions and then for each solution to be analyzed quantitatively. Decision Making in Quality Improvement • Where quality improvement systems exist, decision-making systems are embedded throughout the system of continuous quality improvement. The Kaizen theory and the Shewhart cycle are examples of quality improvement systems with embedded decision systems. – One process that falls under the principles of the Kaizen theory is the Shewhart cycle, also referred to as the Deming model and the plan-do-check-act (PDCA) cycle. Training • Training is a responsibility of leadership and is usually housed in the human resources department. – Training is the main vehicle for human resource development (HRD). • Training is a key role of HRD that works to improve the organization’s effectiveness, efficiency, and efficacy by providing employees with the learning needed to improve their current or future job performance based on the mission, vision, strategies, and goals of the organization. Training, cont. – Training is a planned set of activities that starts with health organizational needs assessment, gap analysis (Do current employees lack certain capabilities?), training module development, trainer identification, logistics of training, the training itself, and training evaluation and refinement. – Training in organizations should focus on the learning of organizationally required knowledge, skills, and abilities (KSAs). – Training of staff and subordinates is, of course, essential for long-term success of the health organization. Training, cont. • “To be successful, training must be designed to: 1. Develop and refine certain of the teachable skills. 2. Improve conceptual abilities. 3. Tap individuals' personal needs, interests, and selfesteem. 4. Help leaders see and move beyond their interpersonal blocks.” – Maltby, D. E. (2009). Leaders: born or made? The state of leadership theory and training today. Biola University. Retrieved July 8, 2009 from http://www.biola.edu/academics/professionalstudies/leadership/resources/leadership/bornormade/. Cultural and Moral Competencies • Cultural and moral competencies are two of the more important health organization training efforts for leaders and their subordinates. Cultural and Moral Competencies, cont. • Cultural competence provides the knowledge, skills, and abilities that allow health leaders to increase their understanding and appreciation of cultural differences among groups of people. – Cultural competency focuses on behaviors, attitudes, and policies. It is this foundation that enables exploration of different cultures, learning about cultural heritages, and the effects of diversity on health care and the health industry. Ethics • Ethics can be defined as a theory of moral values. There is a perception that all organizations are expected to work to the highest standards of integrity and ethics. – Ethical standards and values are not created by law or regulations but are created by the board and trustees of an organization and carried out by the leadership. – Ethics is a framework for decision making and action whereas morality is the level to which the ethical framework is applied. Discussion Questions • Discuss the importance of and use of planning, decision making, and training in health organizations and provide examples of each. How can planning, decision making, and training aid in developing organizational culture in health organizations? • Explain the planning process within the context of leadership. Explain the decision-making processes in health organizations. Predict how successful leaders can be when they master these tools of leadership; what if they do not master these tools? Discussion Questions, cont. • Use examples to apply and relate at least two different decision-making models to a leadership situation in a health organization. How are the models different? When should each model be used in health organizations? • Illustrate the levels or components of the planning process and distinguish each level or component from the other. How does this structure help in planning and in progress review? Discussion Questions, cont. • Relate how a quality improvement program is based on a system of willful choice decision making in a health organization. Can a reality-based decision-making model work in quality improvement? Why or why not? • Compare and contrast willful choice to garbage can models of decision making, training leaders to training staff, and cultural competence to ethics and morality. Justify your positions. Exercises • Define the overall concepts of planning, decision making, and training and give examples of each in your definitions. • Generalize how a successful health leader prepares for: (A) planning in a health organization, (B) developing a decision-making system in a health organization, and (C) ensures all employees are culturally competent in a health organization. Complete this exercise in two pages or less. Exercises, cont. • Prepare a list of internal and external stakeholders for a health organization in preparation of strategic planning categorizing each group. • Compare and contrast in two pages the willful choice and garbage can models of decision making within a health organization context. • Organize a planning effort in preparation for a Kaizen theory or Shewhart cycle quality improvement project within a unit (keep it small) of a health organization in three pages or less. Exercises, cont. • Appraise the concept of “coupling” within the context of decision making, and ethics and morality in a health organization in two to three pages. Chapter 10 Ethics in Health Leadership “Healthcare executives should view ethics as a special charge and responsibility to the patient, client, or others served, the organization and its personnel, themselves and the profession, and, ultimately, but less directly, to society.” American College of Healthcare Executives, 2009 Learning Objectives • Define distributive justice, ethics, morals, and values. Describe how they are used by leaders in decision making. • Explain four ethical principles that guide decision making associated with patient care. • Apply at least two ethical frameworks or distributive justice theories, with examples of moral practice of a leader, to an ethical issue in a health organization. Learning Objectives, cont. • Analyze arguments and make a recommendation for health leaders to adopt utilitarian and/or deontological postures in their organization, and differentiate potential decisions leaders would make between the two frameworks to support your analysis and recommendation. • Compile a list of available options a leader in a health organization has to develop for an integrated system of ethics and moral practice, and summarize the potential impact of each option regarding appropriate ethical adaptation across the organization. Learning Objectives, cont. • Compare and contrast at least three ethical frameworks or distributive justice theories for the topics of patient autonomy, beneficence, nonmaleficence, and justice, and interpret the moral practice associated with those frameworks (at least three) for a right-to-life issue and for the practice of euthanasia. Ethics in Health Leadership • Ethics and the application of ethics, morality, are leadership responsibilities. – Too often, ethics, ethical practice, and discussions of ethics are placed in a legal context of liability reduction and “legalism.” • Health organizational culture development that includes an ethical framework, systems integrated in ethical expectations, and moral practice of ethical actions and behaviors are leadership responsibilities, not legal counsel responsibilities. – Health leaders model the behavior expected in the organization; this especially includes being a moral actor. What Is Ethics? • Ethics is defined as a moral philosophy between concepts of right and wrong behaviors linked to resource allocation. – It deals with values relating to human conduct with respect to the rightness and wrongness of actions and the “goodness” and “badness” of motives. – Ethics in the health field can further be defined as a set of moral principles and rules of conduct for health professionals to follow. What Is Ethics? cont. • Ethics also can, at times, be culturally defined. – This links back to distributive justice theories, cultural values, and beliefs, and how a culture selects and applies a model of resource allocation based on societal norms and mores. Difference Between Ethics, Values, and Morals • Values are enduring beliefs based on some early form of indoctrination and experience. – Values are learned from parents, the community, school, peers, professional organizations, and personal self-development, to name only a few areas. – Recall Rokeach’s model of values–beliefs– attitudes. Difference Between Ethics, Values, and Morals, cont. • Morals are applied practices derived from an ethical framework that is based on values and resource allocation beliefs. Different from values, morals comprise the principals on which decision making is based. – Morality is the level of compliance to an ethical framework. – Morals are the actions and outcomes of the human condition processed over time as evaluated against the ethical framework based on values and resource allocation principles. The Difference Between Ethics, Values, and Morals, cont. • In Aesop’s fable of The Grasshopper and the Ants – The “moral” of this story is that it is always best to prepare for one’s future in the face of the uncertainty of the environment. However, because this “lived experience” may take an individual’s entire lifetime to learn, the experience is shared through the lived experience of others through moral tales. Setting Ethical Standard in the Health Organization • Health leaders face ethical dilemmas in the daily work of delivering health services and products within the health organization. • Health leaders may often find themselves torn between owing allegiance to the financial stability of the organization and the charitable nature of the health profession. • Stakeholder expectations are expressed and integrated through board of directors or board of trustees membership that represents the communities served and the advocacy of stakeholder expectations by senior leadership of the health entity and within internal committee structures of the organization, such as with the ethics committee. Setting Ethical Standard in the Health Organization, cont. • The ethics committee has three main purposes: education, consultation, and policy review. – Challenges of the committee include internal organizational principle conflict, values contradiction, leadership team decision making, and community and industry ethical attitudinal changes. • The health organization should have an individual appointed on staff as the resident ethicist to assist in decision and policy making. • The establishment of an ethics committee that meets on a regular and reoccurring basis can likewise keep the leadership informed of relevant and legitimate issues confronting the health organization. Ethics in Health Leadership • Example: When actions and ethics collide – During the financial collapse of many U.S.-based organizations in the fall of 2008, Congress reacted by providing over $700 billion to organizations that had run themselves into the ground through bad business practices and risky financial behaviors. However, it was later learned that the CEOs of many of these financially insoluble organizations were still going to receive annual bonus checks up to $620,000. Common Ethical Dilemmas • Common ethical dilemmas in health organizations – Ethical dilemmas in health organizations generally arise out of professional, or values-based, conflicts of interest. – According to the American College of Healthcare Executives, a conflict of interest occurs when one has conflicting duties or responsibilities and meeting one of them makes it impossible to meet the other. The classic example occurs when a decision maker for one organization is also a decision maker or influence for another organization with which business is transacted. Relationship Morality • Ethical dilemmas in the health organization are inevitable. In the field of health leadership, ethical dilemmas occur at three levels: micro, macro and meso. – The micro level involves individual issues, such as relationships between individuals and leaders. – The macro level involves societal or community issues that reflect governmental actions or social policies. These are typically culturally based. – The meso level involves organizational or professional issues. Ethics in Health Leadership • Business and financial ethics • Contracts and negotiations Ethics in Health Leadership, cont. • Right to life issues – Roe v. Wade • Euthanasia Ethics of Policy Making in U.S. • Understanding the patient’s spirituality base in decision making – To adjust to the spiritual needs of patients entering the health system, leaders should strive to be aware of the diverse beliefs within their organizations and foster a high degree of sensitivity and respect for those beliefs. – Specific beliefs and practices to consider include, but are not be limited to: • • • • • Healing rituals Dying, death, and care of dead bodies Harvesting and transplanting organs End of life and right to life decisions Use of reproductive technologies Ethical Codes Adopted by Health Industry • Two of these theories are contrasting frameworks: utilitarianism and deontology. • Issues surrounding patient rights of autonomy, beneficence, nonmalificence, and justice important as well. • Common ethical codes or frameworks should be integrated with the cost, quality, and access paradigm considering changes to the health system or resource allocation of health resources. Distributive Justice • At the foundation of ethics is distributive justice. – Distributive justice is a set of theories or ideologies that attempt to instill a set of values, ideals of fairness based on those values, and beliefs in the allocation of resources, food, water, housing, wealth/money, opportunities, materials, etc., throughout a society. Distributive Justice, cont. • At its root, ethics is a framework that is based on a distributive justice theory or combination of those theories; ethics is an extension of resource allocation and the methods of that allocation while morality or morals is the level of congruence to that ethical framework. Utilitarianism • Utilitarianism is a theory that takes as its primary aim the attainment of maximum possible happiness of a society as a whole. • This goal is to be achieved in such a way that one first checks what makes every particular individual in a society happy, then sums up all these various wants and preferences, and finally finds out how to satisfy the greatest number of them. Egalitarianism • Egalitarianism is a set of closely related theories that without exemption advocate the thesis that all members of a society should have exactly equal amount of resources. Libertarianism and Deontology • Libertarianism – Libertarianism suggests that the market or market forces should determine the distribution of resources in a society. • Deontology – Deontology is the opposite of utilitarianism. It is an ethical framework and philosophy of resource allocation that suggests actions should be judged right or wrong based on their own values and principle driven characteristics. Pluralism • Pluralists hold that goods that are normally distributed in any society are too different to be distributed according to only one criterion. To almost every one of these various kinds of goods we should apply a criterion that is characteristic for it. Thus we have diverse spheres of justice in which there are different criteria that tell us which distributions are morally right. Autonomy, Beneficence, Nonmaleficence, and Justice • Autonomy: The patient's right to self governance and medical decision making • Beneficence: The requirement of the health organization to do “good” • Nonmaleficence: The requirement for the health organization to do no harm • Justice: The obligation to give each patient fair resource allocation (services and products associated with the care process) Difference Between Medical Ethics, Clinical Ethics, and Bioethics • Clinical ethics refers to the ethics of the clinical practice of medicine and with ethical problems that arise in the care of patients. – Includes traditional professional medical ethics that place the patient at the center of consideration. • Traditional medical ethics were deficient in the face of technological advances of recent years; this reality has giving rise to bioethics. – Bioethics’ first concern is with “the intersection of ethics and the life sciences” and later expanded to include human values. Difference Between Medical Ethics, Clinical Ethics, and Bioethics, cont. • Health organizations have to balance and develop systems to adhere to medical and clinical ethical standards as well as bioethical standards. Health Leaders Are Part Ethicist Steps to ensuring ethical framework in health organization: • Establishing and chartering ethics committees with authority • Requiring staff attendance, participation, and evaluation of education programs • System of policy development and review • Seeking consultation by utilizing consultants with similar values and moral practices • Integrating professional, clinical, and business ethical performance through leader role modeling and subordinate reinforcement (rewards and punishments) Health Leaders Are Part Ethicist, cont. • Fostering a positive ethical climate within an open and supportive communication environment (For example, it is acceptable to tell leadership about a mistake of error.) • Reviewing relationships with external stakeholders, partners, and entities with which the health organization has contract relationships to evaluate ethical framework and moral practice congruence with the health organization Health Leader’s Challenge: Where to Start? Questions for health leaders to consider when creating ethics system in their organizations: • Which values does the organization hold? • On what distributive justice theoretical framework should ethical decisions be based? – Does that framework apply to all situations and if not, when does the framework not apply and what framework takes its place? − How do values of the health organization get put into practice? Health Leader’s Challenge, cont. • How does a health organization establish an ethical framework and moral application of principles (planning, group discussions, professional associations, laws and regulations, community expectations, community needs, etc.)? • Does the health organization have an ethical statement or creed highly visible and accessible by all stakeholders? Health Leader’s Challenge, cont. • To embed the ethical foundation and moral actions, which systems need to be in place, such as committees, policies, procedures, enforcement of those policies and procedures (consider: should coupling be tight or loose regarding ethical frameworks and moral behavior and actions?), and leadership role modeling considering customers’/patients’ expectations, business conduct and operations, negotiations, contract agreements and compliance, legal/regulation compliance, error remediation (how do you resolve errors made?), and health service and/or product delivery? • How can leadership decisions remain consistent to the ethical framework over time? How do you know you are consistent? Health Leader’s Challenge, cont. • How can organizational culture incorporate the ethical framework and moral application of principles the health organization holds important? • How does the health organization integrate its ethical framework and moral applications into its strategic planning, decision making, and daily operations? Health Leader’s Challenge, cont. • How does the health organization integrate its ethical framework and moral application into the communities they serve and to the interface and external stakeholders of the health organization? • How does the health organization ensure internal staff and subordinate adaptation to the ethical framework and moral application of that framework (training, annual updates, rewards and punishments, etc.) to long-term employees and to new employees (orientation, training, etc.)? Health Leader’s Challenge, cont. • Who keeps the health leadership team accountable to the ethical framework and moral application of established principles? • Is the ethical framework and moral application of those principles reasonable, relevant, and realistic? How are boundaries established? Health Leader’s Challenge, cont. • Who (individuals, groups, legal counsel, etc.) has the authority to initiate an ethical incident report, an ethical discussion, an ethical incident investigation, an ethically attributed reward or punishment? Is the health organization legally or liability oriented to ethical considerations, leadership oriented, or both? (What may be legally “moral” to limit liability may not be leadership “moral” to do what is right.) Regulatory Compliance • Much integrates with governmental payment (reimbursement with taxpayer funds) as part of fiduciary responsibility. • Much deals with private/personal financial gain done outside the care process. • How does the example organization create a system of regulatory compliance? Discussion Questions • Define distributive justice, ethics, morals, values, and conflict of interest. Can you describe how they are used by health leaders in decision making? • Explain four ethical principles that guide decision making associated with patient care. How can leaders use these principles in decision making with a health organization? Discussion Questions, cont. • How could you apply at least two ethical frameworks or distributive justice theories, with examples of moral practice of a leader, to an ethical issue in a health organization? What would be the results? • Should health leaders adopt utilitarian and/or deontological postures in their organization? How could you differentiate potential decisions leaders would make between the two frameworks? Discussion Questions, cont. • What available options does a leader in a health organization have to develop for an integrated system of ethics and moral practice? What would be the potential impact of each option regarding appropriate ethical adaptation across the organization? • How would the utilization of at least three different ethical frameworks (distributive justice theories) react with regard to patient autonomy, beneficence, nonmaleficence, and justice? How would the application of moral practice associated with those frameworks (at least three) be different for a right-tolife issue and for the practice of euthanasia? Exercises • Define distributive justice, ethics, morals, and values. Describe how they are used by leaders in decision making in one page or less. • Explain four ethical principles that guide decision making associated with patient care in one page or less. • Apply at least two ethical frameworks or distributive justice theories, with examples of moral practice of a leader, to an ethical issue in a health organization in two pages or less. Exercises, cont. • Analyze arguments and make a recommendation for health leaders to adopt utilitarian and/or deontological postures in their organization, and differentiate potential decisions leaders would make between the two frameworks to support your analysis and recommendation in two to three pages. Exercises, cont. • Compile a list of available options a leader in a health organization has to develop for an integrated system of ethics and moral practice, and summarize the potential impact of each option regarding appropriate ethical adaptation across the organization in one to two pages. Exercises, cont. • Read the Case Study of the Transferred Employee in the text and answer the following questions in two to three pages. – – – – – – What do you do? Do you change the documents? Do you go back and confront your supervisor? What is your decision and why did you make it? What is your next course of action? What other factors do you consider and what other actions do you take? – Which ethical framework or distributive justice theory best supports your decisions regarding the case and why?
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