BY ALAN SANDERS, Ph.D.
all Street excesses, the mortgage crisis, Penn State, Enron — one does not need to
look very hard over the last decade or so to find examples of organizational ethics
gone awry. Some of these cases involved clearly immoral behavior; others entailed
suspect business decisions. All of them included a culture of practices and policies that reinforced questionable values and silenced persons who raised attention to them.
W
Over time, an organization may lose its soul.
Practices and policies can evolve that are no longer committed to its core values, while many of
the individuals entrenched in the organizational
culture fail to recognize — or they simply ignore
— such changes.
Catholic health care is not immune. In fact,
similar narratives in Catholic health care exist.
Market pressures, outmoded customs and practices and misguided values have led to the end
of some Catholic health care institutions in the
United States.1
Perhaps one lesson from these
examples is that businesses and institutions need
to improve their ability to proactively recognize
and address matters related to organizational
ethics.
Most people in Catholic health care would
likely agree that organizational ethics is important. The term, however, can be elusive in its
meaning and application except when clear and
egregious violations occur. The challenge comes
in identifying matters related to organizational
ethics the rest of the time.2
Organizational ethics reflects upon how an
organization applies its core values to its practices.3
The term covers a wide range of concerns,
and it touches all aspects of an organization.
Issues can develop slowly and transcend staff and
leadership turnover. Often they have innocuous
beginnings, with an evolution that resembles the
metaphor of the frog and boiling water: Throw
a frog into boiling water and it will immediately
jump out. Throw a frog into water that’s at room
temperature, turn the heat up slowly, and the frog
will not notice the incremental changes. By the
time the water boils, it’s too late. Unfortunately
many conversations about organizational ethics
typically occur after the water boils.
In an effort to increase awareness, improve
clarity and add competency in proactively recognizing and addressing organizational ethics, the
mission and ethics department at Catholic Health
East (CHE), in conjunction with mission leaders from across the Newtown Square, Pa.-based
system, created a written guide. The guide introduces organizational ethics to leaders by focusing
on three areas.
SIGNIFICANT ORGANIZATIONAL DECISIONS
CHE uses a system of values-based decision-making to address significant organizational matters.
Similar to discernment processes at other CathoSustaining a Commitment
To Mission and Core Values
ORGANIZATIONAL ETHICS: A GUIDE
72 MAY – JUNE 2013 www.chausa.org HEALTH PROGRESS
Any business or clinical
decision can appear
innocuous but contribute to or
arise out of a larger pattern
of decisions that negatively
affect patient care and
make the organization look
duplicitous.
lic health systems, values-based decision-making
provides guidelines to ensure that all decisions
follow a consistent pattern and process, one that
promotes CHE’s mission and core values. Generally speaking, the process asks participants to
consider the seriousness of an issue and whom it
affects. Next comes discussion of options that best
reflect these concerns. Once options are explored
and chosen, there are specific guidelines for decision-making and follow-through.
Health care leaders typically recognize that
big decisions — those involving joint operating
agreements, opening or closing services, etc. —
are areas of focus for organizational ethics. They
seem to be less aware of how everyday decisions
can reflect, or can be interpreted to reflect, an
organization’s priorities.
For example, a few years ago a friend of mine
went through training to become a certified emergency medical technician (EMT). In the last phase
of her training, she observed two EMTs respond
to an emergency call for a possible cardiac arrest
by slowing down. They were the closest responders to the call, but responding first would have
required them to stay well past the end of their
shift because of the paperwork involved. So they
deliberately tried not to be first on
the scene.
One might immediately blame
the two EMTs. However, my friend
later learned that their company’s
management had decided it was
cheaper to pay for overtime than it
was to hire more EMTs, but overtime was carefully monitored. The
result: many EMTs were reluctant
to work overtime because of the
extra scrutiny and paperwork, and many EMTs
were overworked and burned out because of inadequate staffing. From this perspective, it’s difficult
to place all of the blame on the EMTs my friend
observed. In any event, she never became an EMT.
Such stories and pressures are ubiquitous in
health care. Fee-for-service creates the potential
for unnecessary treatments and tests; bundled
payments and managed care create the potential
to deny needed services; quality indicators can
extend unwarranted treatment in some circumstances and cause short cuts in others; the examples are endless. With regard to organizational
ethics, the point is that any business or clinical
decision can appear innocuous but contribute to
or arise out of a larger pattern of decisions that
negatively affect patient care and make the organization look duplicitous. Keeping an eye out
for such hazards requires not only attention to
decisions; as the EMT example illustrates, it also
requires examining how decisions create policy
and affect an organization’s culture.
ETHICAL REVIEW OF ORGANIZATIONAL POLICY
Ethical review of organizational policy is guided
by the principle that policies are an important
reflection of an organization’s moral character.
Policies are decisions put in writing. As in the
EMT example, policies are proposed by management, approved by governance, carried out
by employees — and they survive individual
employee and leadership turnover. The values
and priorities of the decision-makers become
the current and future guideposts for employee
actions, and these actions become the face of the
organization’s mission.
Only a few policies, such as the organization’s
code of conduct, are commonly viewed as organizational ethics polices. However, all policies
reflect the values and commitments of an institution at some level. Staffing patterns and education
hours, billing and collection practices, employee
benefits and a host of other items send messages
about what an organization values. Although it
is important to ask whether a policy is consistent with an organization’s core values, the policy itself needs to be well-written. Many ethical
problems — though not all — can be prevented or
recognized earlier if the purpose, goal, terms and
processes in the policy are clear and well-defined.
Conflicts of interest policies represent a very
common risk in organizational ethics, and they
illustrate the benefits of writing a policy well.
Typically, a conflicts of interest policy sets limits
HEALTH PROGRESS www.chausa.org MAY – JUNE 2013 73
When the decision is being made,
the board member recuses himself
or herself from the meeting — but
does his or her position on the board
influence the outcome anyway?
money involved isn’t really the point.
From the perspective of this goal and definition, one may see that a conflict of interest can
occur at any level of the organization and may
apply in situations beyond those involving gifts
worth more than a specified sum. For instance,
lunches and small items, if given frequently
enough, could create subtle expectations that the
recipient will, for example, write certain prescriptions, or refer patients to a particular service.4
A
staff member may be invited to attend, at the host
organization’s expense, an educational event at an
(primarily monetary) on gifts and requires disclosure and recusal for leaders based upon a specified amount of money.
However, if the wording of the policy does
nothing but set limits and require disclosure and
recusal, leaders and employees can miss the overall goal: to preserve the organization’s integrity
by encouraging appropriate decision-making. A
well-written policy must make it clear that persons with a responsibility to make choices based
upon the interests of the organization should not
base a decision on personal gain; the amount of
74 MAY – JUNE 2013 www.chausa.org HEALTH PROGRESS
E
thics applies values to action. Organizational ethics addresses decisions, behaviors
and policies over the entire organization
that affect its mission and core values. Generally
speaking, organizational ethics may be divided
into three areas of concern:
1. Significant Organization Decisions
Organizational ethics involve a values-based
decision-making process that can be used for
significant organizational decisions. These are
choices an organization faces that may have
an impact on its identity and structure, as well
as on employee morale. Such decisions may
include:
A joint operating agreement
Opening or closing services
Changes to the workforce
2. How does ethical review of policy work?
Although they often are written to reflect clinical, financial or regulatory requirements, organizational policies also — explicitly or implicitly
— reflect the organization’s values. Examples
may include staffing patterns, hiring practices
and purchasing routines. In addition to ensuring
that such policies align with the organization’s
values, ethical review addresses the following
questions:
Are the goal and purpose of the policy
clearly spelled out?
Are the definitions and criteria clear?
Are lines of authority established and welldefined?
Is the policy consistently applied? How are
exceptions handled?
How does the policy respond to changes
and new information?
Is there an appeals process for complex
decisions, or a system of checks and balances?
Answers to these questions affect whether a
policy is viewed as fair and is followed within the
organization.
3. Considering organizational culture and
behavior
All organizations have a personality — “the way
we do things around here” — both across the
entire organization and within individual departments. These behaviors and practices may
strengthen or weaken its mission. Often questions arise about culture when practices are not
consistent with policy or do not align with the
organization’s values.
Below are some preparatory questions when
addressing organizational culture:
How does the practice relate to the organization’s values?
What are possible explanations for the
practice?
Is the practice an isolated occurrence,
attributable to an individual person, or is it part
of a larger, organizational or departmental pattern?
Is there a policy? If so, do people know
about the policy, and/or is it ignored?
Does a policy need to be created?
Values-based decision-making may be used,
depending on answers to the preparatory questions.
CHE’S ORGANIZATIONAL ETHICS GUIDE
extravagant resort… and the quality of the education is questionable. A not uncommon situation is
that of a board member who (properly) discloses
a financial relationship with a company that submits a bid for a contract. When the decision is
being made, the board member recuses himself or
herself from the meeting — but does his or her
position on the board influence the outcome anyway?
A conflicts of interest policy could not possibly
address all potential conflicts, nor should a conflicts of interest policy eliminate all gifts, contacts
and relationships. However, a well-written policy can help employees and leaders identify and
manage the conflicts more broadly. For example,
they might give consideration to the frequency
of gifts, not just set financial limits; pay attention
to the appearances of decisions, not just to fair
processes; and outline ways to manage possible
undue influence, not just require disclosure and
recusal.
Besides helping to create a well-written policy,
an ethical review asks whom the policy affects,
who should have input into its creation and what
messages the policy sends to employees and the
public about the organization’s priorities. Asking
these questions up front can help prevent or mitigate a policy’s unintended or unforeseen consequences. If the EMT company had addressed these
questions, for instance, it might have escaped creating a culture of slowing down for emergency
calls — and the impression it forever left upon my
friend.
ORGANIZATIONAL CULTURE AND BEHAVIOR
Organizational culture is very complex. People
typically talk about it in terms such as “the way
we do things around here.”5
There are many types
of organizational culture, and they manifest themselves in various ways. Just to name a few, an organization may have a culture of following policies
to the letter (“we make no exceptions”), ignoring policies (turning a blind eye to smoking on a
smoke-free campus), autocratic rule (“don’t question my authority”) or using a values-base discernment process (collaborative decision-making).
The CHE guide does not intend to educate persons about the intricacies of organizational culture. Rather, it offers questions intended to help
health care organizations determine whether a
specific matter is due to culture or is more reflective of one person or a smaller group. There are
also questions that ask about existing policy and
whether colleagues know about it or ignore it, as
well as questions that will indicate whether a policy needs to be created.
CHE’s ministry formation programs address
culture, and leaders who participate commonly
say that while everyone in an organization contributes to culture, some individuals and groups
have significant influence. Significant contributors include physicians, the local community and
the local history of the organization (e.g. charisms
of the nuns), they say. They also mention informal
leaders — those who have influence regardless of
official title or level in the organization. Interestingly, leaders mention themselves most often as
significant contributors. They say that leadership
sets the tone for an organization by “walking the
talk,” embracing the mission and vision of an organization and engaging employees or, conversely,
being disengaged and appearing hypocritical.
The challenge for organizational ethics is that
culture is difficult to measure. It goes unnoticed
by many (like the frog in the water), and there are
others who do not want to talk about it openly.
One way to assess an organization’s culture is
through existing human resource mechanisms.
Employee relations, satisfaction surveys, staff
turnover and exit interviews are natural places to
look for a sense of an organization’s culture. Even
a compliance hotline can provide clues, especially
if there are patterns and similarities in the reports.
Regular reviews of adverse events can reveal elements of culture.
There also are informal ways to get a sense of
an organization’s culture. They include rounding
or checking in with employees on a regular basis
and listening with a discerning ear to gossip. Some
committees and groups take time at regular meetings to chat about how everything is going around
the office or company or organization — which
admittedly requires the group to already possess
a somewhat open and trusting culture.
The principles of Catholic social teaching
— justice, human dignity, the common good
— are natural guides for Catholic health care
organizations in creating and fostering a healthy
Employee relations,
satisfaction surveys, staff
turnover and exit interviews
are natural places to look for
a sense of an organization’s
culture.
HEALTH PROGRESS www.chausa.org MAY – JUNE 2013 75
committees as needed to address organizational
ethics issues. Currently these groups tend to be
assembled when a significant organizational decision or policy is at hand, such as closing a service
line or considering a policy about hiring smokers.
Some local organizations have standing committees. Saint Joseph’s Hospital in Atlanta has
a mission effectiveness committee comprising
senior management and representatives from the
board. Similarly, St. Mary Medical
Center in Langhorne, Pa., has a ministry committee of the board. Both
committees commonly address
matters related to significant organizational decisions and making
ethical reviews of organizational
policy.
BayCare Health System in
Tampa, Fla., has a corporate responsibility council, an interdisciplinary
management and senior management committee that attends to compliance matters as well as
those that fall under the heading of organizational
culture and behavior. Additionally, all CHE local
organizations have an interdisciplinary management-level compliance committee with the capability of handling reported or identified risks.
As the EMT example illustrates, clinical ethics
and organizational ethics are not mutually exclusive.10 However, it is unlikely that the clinical ethics committee, as traditionally structured in most
situations, can adequately address many matters
related to organizational ethics. First, many organizational ethics decisions need to be addressed
at a more senior level than typically represented
on traditional clinical ethics committees. Second,
the common bioethical principles and approaches
often applied to cases in clinical ethics — patient
autonomy, the family meeting — are not sufficient
for addressing matters related to organizational
ethics.
It is clear that organizational ethics is everyone’s responsibility. CHE currently addresses
many aspects of organizational ethics via relations between mission and ethics, compliance and
human resources, but in the long term, more work
needs to be done. There are still questions about
how and when to incorporate other areas such as
quality, finance and information technology, just
to name a few.
Also, because organizational ethics is young,
we don’t know what we don’t know. With this in
mind, CHE has formed an interdisciplinary organizational ethics forum involving leadership from
across the system and led by the system office mission and ethics department. The forum’s overall
culture.6
They are the foundation of the core
values listed in all Catholic health care mission
statements across the United States. Indeed, some
consider the principles to be the best-kept secret
of Catholic health care.7
For example, the principle of subsidiarity holds
that organizational matters should be handled at
the smallest, lowest or least-centralized level of
the organization capable to address them (or at
minimum, involve these persons or their perspectives appropriately in the decision-making
process). This principle challenges the hierarchy
traditional in medicine. However, many stories
about organizational failure involve leaders who
make decisions in isolation, overlook the longterm impact of their decisions and have a narrow
view of who is affected. Integrating the principle
of subsidiarity can mitigate this risk.8
Attention to Catholic social teaching and
related principles — existing mission statements
and the Ethical and Religious Directives for Catholic Health Care Services (ERDs) — can help Catholic health care organizations look beyond existing legal and regulatory requirements to create
and sustain a culture that is in the spirit of the
founding sponsors. Examples include ensuring
that Catholic values and principles are included
in employee satisfaction surveys and exit interviews; using them in the process of hiring for “fit”
and in drawing up job descriptions that outline
expected behaviors and practices.9
Recognition,
awards, storytelling, core-value education and
integrating reflective time at regular meetings
also can encourage and sustain a culture that is
consistent with Catholic social principles.
MOVING FORWARD
Compared to clinical bioethics, in which there
are well-established mechanisms such as the clinical ethics committee and rules such as informed
consent, organizational ethics is very young.
Examining organizational ethics through the lens
of decisions, policies and culture may help in identifying and addressing issues. CHE encourages its
local organizations to, at minimum, form ad-hoc
76 MAY – JUNE 2013 www.chausa.org HEALTH PROGRESS
It is unlikely that the clinical ethics
committee, as traditionally structured
in most situations, can adequately
address many matters related to
organizational ethics.
Five Ethicists Help Define and Contextualize an Elusive
Topic,” Health Progress 87, no. 6 (Nov.-Dec. 2006):
28-33.
3. Philip J. Boyle et al., Organizational Ethics in Health
Care: Principles, Cases, and Practical Solutions (San
Francisco: Jossey-Bass, 2001).
4. Michael R. Panicola and Ron Hamel, “Industry-Physician Relationships: A Call for Greater Distance,” Health
Progress 90, no. 4 (July-Aug. 2009): 62-68.
5. Leonard J. Weber, Business Ethics in Healthcare:
Beyond Compliance (Bloomington, Ind.: Indiana University Press, 2001).
6. William J. Byron, “Ten Building Blocks of Catholic
Social Teaching,” America (Oct. 31, 1998): 9-12.
7. Edward P. Deberri et al., Catholic Social Teaching: Our
Best Kept Secret, Fourth Edition (Maryknoll, N.Y.: Orbis
Books, 2003).
8. Joel E. Urbany, Thomas J. Reynolds and Joan M. Phillips, “How to Make Values Count in Everyday Decisions,”
MIT Sloan Management Review 49, no. 4 (Summer
2008): 75-80.
9. Brian O’Toole, “The Hallmark of Catholic Identity: Four
Methodologies to Make This Real and Lasting,” Health
Progress 80, no. 3 (May-June 2008): 46-51.
10. Sally Bean, “Navigating the Murky Intersection
between Clinical and Organizational Ethics: A Hybrid
Case Taxonomy,” Bioethics 25, no. 6 (July 2011): 320-
325.
goal is exploratory and educational. It will help
local entities identify and discern about matters
related to organizational ethics, in the hope of
adding clarity and capacity across the system. The
forum will address issues shared by more than
one ministry within CHE, starting with conflicts
of interests and policies about hiring (or not hiring) smokers.
In summary, organizational ethics in Catholic
health care and its commitment to mission and
core values do not include matters only related to
prohibited procedures, joint ventures and appropriate relationships with other organizations.
These matters are important, but, in many ways,
they might represent only a small portion of organizational risks. Others pertain to how decisions
are made, policies are created and culture is lived
out — items that relate to any business whose
identity and core values are a key driver to success and sustainability.
ALAN SANDERS is director, ethics, Catholic Health
East, Newtown Square, Pa.
NOTES
1. Daniel P. Sulmasy, “Then There Was One,” America
200, no. 9 (March 16, 2009).
2. Editors, “Shedding Light on Organizational Ethics:
HEALTH PROGRESS www.chausa.org MAY – JUNE 2013 77
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