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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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