The mission and value statements of healthcare organizations serve as the foundational philosophy that informs all aspects of their organizations. Mission statements describe the fundamental activities of an organization such as education, research, patient care, and health promotion. The organization’s values are captured in values statements to clarify what the organization stands for, and how it will seek to achieve the stated mission. The values commonly expressed include ethically-grounded concepts such as ‘Respect for patients,’ ‘Justice,’ ‘Stewardship of Resources,’ ‘Integrity,’ ‘Transparency,’ and ‘Teamwork.’ “When taken together, the mission and values statements serve as the organization’s core philosophy.”Footnote 1 For staff, the statements function as explicated assertions of expectations related to their practices, culture, and decisions-making. The organization’s mission and values statements provide patients and the population served with an understanding of what to expect from the organization. As the core philosophy is integrated throughout the organization, it becomes an effective branding tool.
The ultimate goal is seamless alignment of values to mission in a fashion that colors the overall life and culture of the organization.Footnote 2 Healthcare organizational success is built when decisions are seen as consistently in line with stated values, and staff feel they work in an environment of transparency and authenticity to its core philosophy.
Full alignment between healthcare organizational values and mission, in a fashion that influences their daily life and culture, does not always occur. Staff may be unaware of the organization’s mission and values. Or when leaders make some attempt to propagate the organization’s mission and values, staff may feel little commitment to it. As Kurt Darr writes, “If little attention is paid to the organization’s stated moral values, it is obvious staff can pay no attention to it.” Footnote 3 Respondents of a recent survey study acknowledged the importance of value-focused statements to the mission of healthcare organizations, yet, a large majority of respondents indicated that a gap exists between of patient-centered values and day-to-day patient care in their organizations. Many respondents cited misaligned organizational actions that they felt ran contrary to the moral mandate to deliver patient-centered care.Footnote 4
Some healthcare organizations work to link explicit organizational values and the lived experience of front-line providers via the formation of ethics task forces. Ethics task forces grapple with organizational ethics issues using processes taken from the operational change and quality improvement literature.Footnote 5 Even so, a disconnect between explicit values of an organization, and actual organizational decisions and the lived experience of the people who work there, can still occur.
We believe the lack of alignment of organizational actions to the explicit organizational mission and value statements often stems from the failure to develop processes that enable realization of the leadership’s good intentions. This may reflect an unawareness of gaps in the alignment of organizational practices and culture with organizational mission and values. Others have noted there can be healthcare ‘organizational blindness’ to the existence of alignment gaps, and to the cultural and practical obstacles to the realization of ethically-relevant organizational goals. Such blindness can lead to, or be the result of, insufficient resources to staff and support the development of processes that align organizational actions to organizational mission and values.Footnote 6
To support full realization of the ethics-grounded goals of their mission and values, we have developed an organizational ethics dashboard to empower leaders of healthcare organizations to assess the adequacy of systems in place to support alignment with stated ethical mission (Figure 1).
Figure 1. Organizational ethics dashboard.
This organizational ethics dashboard is intended to empower the leadership of healthcare organizations to identify specific ways they can realize the ethical alignment set out in the mission and values statement, as well as to monitor the success of these efforts. We break these measures into two categories: inclusion of ethics expertise (in the form of an ethicist or another strong, ethics-savvy leader) into pivotal aspects of organizational decisionmaking; and the development of ethics-related metrics that organizational leaders can use to track the success of their efforts to align to the ethical goals of the organizational mission.
Organizational Decisionmaking
For an organization to behave in an ethically aligned manner, its leaders must consider ethical concerns when making important decisions. This involves ethical sensitivity and reflection on the part of leaders of organizations, and also utilization of ethics resources when appropriate for sophisticated ethical scenarios.
If a leader frames her role as not only fiscal but also about ethical stewardship, and then makes financial and strategic decisions with this ethical role in mind, we believe she is more likely to lead the organization to full realization of its stated ethical goals. Harvard Ethicist Jim Sabin has noted that if the CEO is not seen as the “Chief Ethics Officer,” then it will be a struggle to achieve organizational ethical alignment.Footnote 7 The sensitivity to, and engagement with, the ethical component of leadership is itself the single most important way a leader ensures their organization is ethically aligned.
Much as ethical thinking is a critical component of healthcare leadership, we should not expect healthcare leaders to lead without adequate ethical backup. We expect healthcare leaders to not only recognize the presence of ethical issues related to their decisionmaking, but the need to seek the insights from knowledgeable resources when their ethics background is inadequate in various situations. We expect healthcare leaders to consult with experts in finance and population health when making complicated strategic decisions, and should expect the same of ethically-complicated decisions.
For example, a metropolitan healthcare system is considering closing one its four outpatient clinics, located in an area that is social-economically depressed. The area is in great need of the clinic: however, due to the changing payer mix, the clinic has become a financial drain on the health system and has been identified as having a negative impact on the organization’s margin. During the executive level discussion regarding the potential closing the clinic, one leader points out that this is not just a financial issue, it is an ethical issue— “Is the organization morally justified to close a needed clinic serving a vulnerable population to increase the financial margin?”
This case exemplifies two points. First, there is need for leaders to recognize the ethical concerns, conflicts, and questions related to managerial decisionmaking. It is critical not to focus so fixedly on financial, clinical and/or legal aspects of a decision that underlying ethical ramifications are neglected. Second, ethics resources can support robust reflection when ethical issues arise. It can be challenging to identify ways of drawing on ethics expertise, when needed in some settings. An executive leadership team of a small organization may make financial, staffing, and communication decisions on a regular basis without the availability of ethics expertise. Thus, having an ethics expert in their strategy group could be challenging. In such situations, leaders need to grow their ethics reflection knowledge and skills to effectively serve the institution. On the other hand, some large health systems needing to make resource allocation decisions, or develop institutional policies that have complex ethical ramifications on a regular basis, would benefit from including ethics expertise on the executive leadership team or another strategy group. We are not suggesting in this example that only large institutions will need ethicist expertise for organizational decisionmaking. The complexities of each type of system are distinct and not amenable to such simplistic distinctions. Rather, we can imagine different organizations developing different organizationally-appropriate solutions to their ethics needs, and envision the dashboard as a tool to support healthcare leaders in that work, so they can not only gauge the adequacy of their current process, but also track the success of any changes they make.
Given the high variation in complexity of decisions faced by organizations of different sizes (and other traits), it is key for institutional leadership to consider how often they are making complex ethical decisions that would merit either from periodic ethics consultation or embedded ethics expertise. Some decisions faced by healthcare organizations are more ethically fraught than others, and can benefit from leadership consideration of solicitation of organization ethics expertise. This in turn raises the question: Which decisions are complex enough to benefit from expert ethics input?
The previous case example also suggests when ethics expertise can be valuable: when the organization faces an issue that is both complex and high-stakes. The decision to close an outpatient clinic that serves a predominantly poor neighborhood, for which the institution may be the final resource, is ethically complex because it pushes decisionmakers to rank organizational values. Also, it is high-stakes in that it could result in loss of access to healthcare for a vulnerable population and may affect organizational relationships with the surrounding community adversely. Additional instances when ethics expertise resources are needed include times when involved decisionmakers lack an ethically-grounded consensus concerning a response to the ethics issue or question. This can be recognized either before a decision is made; in the wake of unanticipated blowback; or when clinical and executives’ ethical intuitions are not sufficient in resolving competing values and are creating that lack of consensus.
End-of-life decisionmaking on a population level, such as the implementation of new advance directive policies, can also give rise to complicated organizational ethics concerns that may benefit from expert ethics input. The formulation or revision of institutional conflict of interest policies can also require leaders to balance interests like quality of care, clinician financial gain, and clinician autonomy, and may thus benefit from expert ethics input.
One venue in which ethics expertise can be invaluable is in committees tasked by the organization with managing providers with lapses in professionalism. Inevitably, these groups take on challenging questions like whether to allow a clinician struggling with addiction to continue seeing patients while getting treatment, or whether a provider’s poor performance on clinical metrics is problematic enough to warrant furlough, even if this has an adverse impact on the call schedules of colleagues. Yet, the ethical resolution of such challenging decisions, and the consequent creation of a culture of transparency and trust, can be vital to the creation of a nimble and effective organizational culture. Our experience is that all organizations manage problematic behavior; healthy organizations foster an expectation among their members that such issues will be managed quickly, transparently, and fairly.
The ethics expert needed to be an effective resource to address the complex organizational ethical challenges requires specific knowledge and skills. An ethicist focusing on organizational ethics issues needs to possess a broader and different knowledge base than what is required in addressing traditionally focused clinical ethics issues, such as a disagreement regarding the removal of life-sustaining treatment in the intensive care unit. Effective support for organizational ethics alignment even amid complex issues requires knowledge in the ethical practices of business and management. In 2013, an American Society for Bioethics and Humanities task force published guidelines for professionals performing ethics consultation.Footnote 8 The updated guidelines significantly expanded the scope of the competencies from the previous published competencies, especially focusing on the needed knowledge and skills for addressing the growing organizational ethical challenges.
Organizations need to financially support the availability of ethics expertise in order to assure availability of periodic or embedded input. This can involve dedicated support for an organizational ethicist, provision of partial FTE support for individuals with ethics expertise that complements other institutional roles, or formulation of individual professional roles to include acquisition and promulgation of ethics expertise. For example, an institutional nurse leader, possessing a master’s degree in bioethics, with a focus on organization ethics, could serve as the organizational ethics resource.
Upon engagement of adequately resourced ethics expertise, and inclusion as appropriate to the tempo of organizational ethics needs, organizations can benefit from public sharing of the ways they are promoting the organization’s stated values. This not only helps increase awareness of a supported ethics resource but can also aid in the creation of a transparent, ethics-oriented, organizational culture. These public affirmations of the organization’s ethical alignment can link to institutional quality efforts, and help support staff morale and buy-in to institutional mission that can help leaders succeed in other contentious efforts such as cost saving measures, transitions to new electronic records, etc.
When the organization ensures that ethics expertise is adequately supported, the presence of the organizational ethics dashboard can help ensure the work of that individual is prominent, and tracked effectively.
Organizational Ethics Metrics
Healthcare organizations should be outcome-obsessed. This applies to efforts to achieve alignment to the ethical aspects of the organization’s mission as well as its values. There are multiple metrics organizational leaders, and their ethics-expert colleagues, can track to assure successful ethical alignment. In Figure 1, we suggest potential metrics for an organizational ethics dashboard.
Some metrics pertain to the institution’s engagement in efforts known to address patient ethical needs. For example, what percentage of the inpatient and outpatient population have completed an advance directive? What percentage of the institution’s accountable population died in the hospital versus at home, or in hospice care? How much does the institution invest each year in charitable care?
Staff assessment of the organizational culture—through surveys and/or focus groups—is a powerful measure of organizational ethics alignment. Do staff—from physicians to nurses, and executives to janitors—believe they work in a culture of transparency and trust? Do they trust that leadership is listening, concerned, and capable? Does the staff believe that the organization is trying to align to its explicit mission and values, including ethical values like being a strong community partner that serves the needs of vulnerable populations? Is burnout rampant? Is job turnover high? How likely are staff to seek other employment in the coming year? Each has many inputs. For example, when staff are leaving the institution, is there an attempt to conduct exit interviews—what lessons can the organization gain as to why a staff decided to leave? The use of surveys, focus groups, and interviews speaks to organizational culture, which can in turn be affected by how effectively the mission and values are captured in the behaviors of staff, and felt as an intimate part of the daily work. For example, the United States Department of Veterans Affairs has used an ethics staff survey to assess how employees view eight attributes of an ethical organization.Footnote 9,Footnote 10
Specific ethics-relevant metrics merit additional mention. The number of clinical and organizational ethics consultations completed each year can be an informative metric to track, although judicious interpretation is required. A low number of consultations may indicate that few ethical issues have arisen, or that due to solid ethics education, staff feel competent to address the issues without consulting ethics resources. On the other hand, a low number of consultations could suggest that healthcare professionals either do not recognize the ethical issue, or lack the insight to seek assistance. A large number of consults can indicate robust institutional ethics resources, or that there are underlying systems issues triggering a recurring pattern of concern. Other important end-of-life metrics include: the percentage of patients with a completed advance directive on file from fewer than two years ago, or the average intensive care unit and hospital length of stay prior to conversion to hospice.
Patient surveys, similarly, can gauge success of organizational alignment to ethical mission. Did patients feel they and their privacy were respected? Were they given enough information, and enough time to ask questions, to make truly informed decisions about their healthcare? If patients complained, did the institution respond reasonably? As with staff surveys and focus groups, the outcomes of similar assessments of patient impressions of the organizational culture are driven by many factors, including organizational alignment to its ethical mission.
Surveys of community leaders, from local governmental officials to faith-based leaders and beyond, can also assess the population-level impact of the organization’s ethical culture. Is the organization perceived to help when an urgent community need, such as an outbreak of an infectious disease, arises? Did the organization respond to community perception of its health needs, rather than imposing on the community the organization’s sense of what is most important? In its negotiations with the community, such as around real estate, fair wages, and union policy, is the organization seen as fair and transparent?
The success of the organization’s alignment to its ethical mission can also be gauged, at least in part, by the presence or absence of employment disputes or other markers of high staff turnover.
These metrics can help leaders hold ethics-expert staff accountable and help measure the impact of interventions aimed at improving alignment to ethical mission. For instance, if the leader is swayed by organizational ethics expertise to invest in an unprofitable outpatient health center because it serves the needs of a vulnerable population, does that decision lead to enhanced community relations and improved clinical outcomes among high-risk patients who draw on institutional charity care?
Conclusion
We believe that healthcare organizations will ultimately be more successful when leadership decisions and organizational culture are overtly congruent with explicit mission and values. Healthcare leaders with good intentions and full intent to lead an organizational culture can, nonetheless, invest inadequately in an ethical culture via excessive focus on the organization’s financial and strategic concerns. The dashboard we propose seeks to enable leaders to evaluate the adequacy of their investment in organizational ethical culture and the ethical organizational decisions that follow. Healthcare leaders may use the dashboard to confirm that they are leading an ethical healthcare organization. Others may identify blind spots, and in turn, support the identification of subordinates who can be accountable to carrying out that work.
