Doing what’s right for patients isn’t always good business

Providers define values and stick with them

When a young woman came to her hospital’s emergency department suffering from hyperglycemia, Serena Fox, MD, found herself in the uncomfortable position of being both physician and patient advocate. The woman was a newly diagnosed diabetic, and usually such patients are kept under hospital observation long enough to get sugar levels under control. Fox wanted to keep the woman for a second day but learned that this seemingly simple and routine hospital stay was not covered by the patient’s managed care plan.

After spending an afternoon making phone calls to the HMO, Fox got an extension for her patient. She also found that the one-day-only policy was new and had been implemented by a non-physician.

"This was an eye-opening experience for me," says Fox, medical director of adult intensive care at Columbia Hospital for Women in Washington, DC, and a member of the bioethics consult team of the Washington Hospital Center (WHC), also in the nation’s capital.

When physicians like Fox are asked to serve two masters — the patient and the hospital as a business — ethical conflict is all but inevitable, says Paul M. Schyve, MD, senior vice president of the Joint Commission on Accreditation of Healthcare Organizations.

Faced with stiff competition and managed care contractual agreements that call for cost containment, doctors and hospital administrators often find themselves at odds over what is the "right" treatment option, the "right" amount of charity care, or even the "right" time management practice for a physician.

Does your ethics code work?

This year marks the first time the Joint Commission’s new standards on organizational ethics and its code of ethical behavior will have a direct impact on your institution’s accreditation. "The standard will not only be whether you have a written code of behavior, but rather, does it really work?" Schyve explains. This makes the involvement of your institution’s ethics committee critical to appropriate decision making. (See details of standard and interpretations, p. 27.)

"Many ethics committee members will shy away from organizational ethics and see only their bedside role," says Janicemarie K. Vinicky, PhD, director of the department of bioethics at WHC. But the line between business and clinical ethics is often blurred.

When there are competing values, you have to ask what impact your decision will have on the quality of care for the patient. "You have to understand the ramifications of your decision and be accountable for it," Schyve contends.

"The knowledge and skills that ethics committee members have need to be applied to business ethics for the sake of the patient, the health care professional, and the institution," he argues.

Vinicky suggests that ethics committees can address organizational ethics through a subcommittee or task force or by inviting finance, human resources, and managed care staff to meetings.

Keep in mind that the goal is to develop an ethics infrastructure, not to create a list of dos and don’ts, says Myra J. Christopher, executive director of the Midwest Bioethics Center in Kansas City, MO. The group’s educational arm, the Bioethics Development Group has worked with the Joint Commission for the past three years to offer organizational ethics information and training to a number of hospitals nationwide.

Often a phone inquiry to the educational group involves a hospital chief executive officer (CEO) asking for lists and written materials, says Christopher. Some administrators have trouble understanding that ethics must be a day-to-day part of every decision, whether that decision is made at the bedside or in the board room. "Developing organizational ethics means that you have values criteria against which all decisions are made," she explains.

Good practice

These experts say the successful approach to organizational ethics is long-term and has four fundamental steps:

1. Assign responsibility: Appoint a coordinator. This may be a full-time employee with a variety of ethics responsibilities, says Christopher. It must be someone who is known and respected throughout the institution and who can devote a significant amount of time to ethics.

2. Define and prioritize the values of the institution. Start with multiple committees or small group discussions of personal values and then develop a plan to identify institutional values. Take a "values audit." You may list such things as compassion, educational excellence, and intellectual honesty. Cluster the values, then prioritize and narrow them down to a workable list.

Review all of the institution’s core documents such as its mission statement, strategic plan, marketing materials, medical staff bylaws, and human resources procedures for hiring, evaluation, and staff promotions. Also review any presentations that your CEO and chief financial officer make to important constituency groups such as the board of directors or a managed care network.

A values audit should open a forum for discussion on global issues and determine what issues your organization is not ready to set aside in a written code of behavior.

"The balance of cost shifting is getting tighter and tighter under managed care. For a hospital like ours [a major trauma center] we have to question how much free care we can provide," says Vinicky. "What is our obligation to the community as a whole?" For hospitals like WHC that traditionally have offered a substantial amount of charity care, this is not an easy dilemma. But Vinicky contends it is one that hospital ethics committees must raise continually.

While global issues will require more attention, many other issues are clarified easily. A values audit can reveal clearly, for example, when business decisions raise ethical concerns, says Schyve. If your organization values honesty and open communication, gag clauses in a managed care contract would be unacceptable, he says.

Anything that "constrains the clinician or the hospital from acting in the best interests of the patient is likewise questionable. If the doctor’s or the hospital’s reimbursement from a managed care organization will be bigger at the end of the year if they hold back care, this obviously can influence the patient in a perverse way," Schyve warns.

Once you have reviewed the values of your institution, prioritize them, says Christopher. Ask staff participants which values they are willing to compromise on and which they would fight to retain. This shows the Joint Commission and others that you have developed a thoughtful process, not a template solution to a requirement, she says.

3. Communicate your core values and code of behavior throughout the institution. "Make a statement that this is the ethical framework your institution is committed to," Christopher says. Make sure staff understand the implicit values. Put your standards in writing as a code of ethical business behavior and live by them, she recommends.

4. Monitor and evaluate compliance. "Your organization needs to understand that it is going to take time to create an ethics infrastructure," says Christopher. There is no single model; your plan has to fit the political environment of your institution, she warns. Make sure you have the commitment and support of top management.

"We have to substantiate clear ethical arguments, and then health care executives will come to realize that good ethics is inextricably tied to good business," Christopher contends.