1. How to Analyze Organizational Ethics: The Case of Resource Allocation Philip Boyle, Ph.D. Vice President, Mission & Ethics www.CHE.ORG/ETHICS

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3. Goals for today’s conversation How to analyze a case –Examining policies –Examining culture (gap between policy & practice) Resource allocation –Why it is a key issue in org ethics? –What marks a defensible resource allocation?

4. Importance of resource allocation? Resources are at means to accomplish mission Expresses the moral character of organization –Policies proposed by management, approved by board, carried out by colleagues

5. Resource allocation Happenstance or intentional Different goals –Cost containment, appropriate care Different practical responses –Don’t ask, don’t tell –Tell, but don’t ask –Tell, and ask

6. Done everywhere--micro Triage Admission & transfer Futility Purchasing Practice parameters Formulary Staffing patterns Equipment

7. Micro –First come, first serve presupposes access to info –Status: based on society’s sympathies –Merit: past & future contribution –Quality of life / prognosis: discriminatory? –Neediest/worst-off –Age: natural life span –Lottery: only if all things are equal –Those who can afford it –Alternatives Forfeiture Gate keeping

8. What are essential elements of VBDM?

10. Why use it? Consistent evidence of supporting Mission Evidence of Participation and Respect for Persons Evidence that the Spirit has guided Checks & Balances Fosters habit of moral reasoning

11. When to use it? Formally Decision that affect significant interests and populations Opening Closing Services Significant HR issues Development of Strategic management tools Informally—all moral decisions

12. 1 of 10 high LOS & $1 million+ Healthy 78-year-old man in ER with turkey bone in throat ER MD ruptures patient’s esophagus ruptured. Surgeon attempted several repairs Patient became septic; acute liver and kidney failure and respiratory failure and required mechanical ventilation and hemodialysis.

13. 1 of 10 high LOS & $1 million+ Patient was restless, grimacing, and neurologically unresponsive. The staff believed he should be transferred out of the ICU because he was “moribund.” ICU staff was aware that for rupture of the esophagus the literature reflects nearly a 100 % mortality rate. Surgeon has had good-but unpublished-results with patients of this sort; he regularly defends his potion with other consultants who maintain the patient is likely to expire early on during the course of treatment.

14. Policy Purpose: To define assessment criteria (that constitute safe parameters) for transfer or discharge of patients from a critical care unit. 1.Vital signs are assessed as stable for the individual patient as agreed upon by the attending physician and nurse caring for the patient four (4) hours prior to transfer. 2. Neurological status is assessed to be either the patient's normal preadmission level or at a level of stability that does not require further critical care nursing interventions for four (4) hours prior to transfer. 3. Respiratory status is assessed to be such that the patient is able to maintain adequate ventilation and oxygenation without mechanical assistance four (4) hours prior to transfer. 4. Cardiovascular status is assessed to be such that the patient's tissue perfusion is adequate. 5. Cardiovascular status is assessed to be such that all life-threatening dysrhythmias have resolved to the point where certain IV cardiac medications which are given only in critical care units are no longer necessary to control the dysrhythmia or regulate vascular tone four (4) hours prior to transfer. 6. Fluid and electrolyte status is assessed to be within reasonable limits for the individual patient four (4) hours prior to transfer. 7. Any patient may be discharged from the critical care unit who is determined to be moribund in the assessment of the attending physician and for whom no extraordinary medical measures will be used to prolong life or prevent death.

15. Phase I: Preparation Number of persons/groups impacted –Does it affect a department or the institution? Duration of the impact –Does the impact last a few years or the span of the ministry? Depth or weight of impact – Does the question affect the entire ministry or a portion of it? Closeness to Core Values –Does the question directly jeopardize a value? Degree of complexity Past commitments –Does the question positively or negatively affect past commitments? Relationship to strategic direction

16. Whose interests are affected? Based on the nature of the issue, what other individuals or groups need to be part of the process? What is the nature and frequency of the connection between the groups and the question? What departments will be affected? What departments might have insight? What other entities will be affected by the decision? Who would have insights to the Mission and tradition as it applies to this decision? Who should participate?

17. Phase II: Decision Making 1.Pray, reflect, identify question, and clarify authority of decision-making group. Groups scope of authority Ground rules for participation Issue identification

18. Phase II: Decision Making 2. Determine primary and secondary communities of concern and their interests. While there may be a large community of concern, not everyone in that community has the same interests. The decision-making group should assess the manner and degree to which a sub-community will be affected positively and/or negatively. The decision-making group should consider how those who are poor and vulnerable will be affected by the decision.

19. Phase II: Decision Making 3. Pinpoint and gather needed information and data. What essential data have been gathered already? What essential data have yet to be gathered? Once data are gathered, does the group agree on its relevance, accuracy, and completeness?

20. Resource allocation Formal analysis –Are the definitions clear? –Is it clear about who should decide? –Are there checks and balances? –Is the resource allocation just applied only to the vulnerable dying or to all instances?

21. Allocating Resources Formal & informal mechanisms –Is informal still used? –Are they applied evenly? Which resources should be managed?

22. Measurement employed Medical or social? What unit is measured? Single intervention or episode? Effectiveness: effective for what, how long, who judges? Severity of illness Costs: which should count? Length? Social measurements?

23. Resource allocation Informal analysis –Is the policy evenly applied or are there variable interpretations? –How does the mechanism work? Was there a previous informal mechanism? Who devised & when is it used? What is the purpose of the mechanism –What are the goals of the mechanism? Whose goals? Does it meet the goal?

24. Phase II: Decision Making 4. Identify key moral commitments and values, as well as conflicts among them. Identify the question in terms of trade-offs between one or more values. For example, consider your decision in terms of human dignity and identify the dignity trade-offs in the various options that you are weighing. Identify the major consequences of this dignity trade-off in terms of individuals and groups; in terms of long- and short-term burdens and benefits; or in terms of money, morale and relationships, etc.

25. Phase II: Decision Making 5. Establish priorities among commitments and values. The moral commitments and values that deserve priority will flow from consideration of strategic goals/objectives, core values, historical commitments, the broader religious tradition, and special circumstances. List each priority and provide the rationale for why it is a priority.

26. Phase II: Decision Making 6. Develop options that support the priorities. Identify options that promote the moral commitments and values deserving priority. Examine carefully the major options and evaluate the positive and negative consequences of these options on the identified priorities. Consider not only the burdens and benefits of the preferred option but all of the options. Do any of the options preserve and protect a majority of the identified priorities?

27. Due process –notice, in this case information why and what alternatives exist –means of meaningful appeal –consistency in judgment and action –transparency to the public and all those who will affected by the choices –checks & balances

28. Fair allocation A process that is marked by the following qualities: It is viewed as fair It allows for transparency for others to see how the decision was made It is shown to adjust its decision as new facts come to light It reflects that the interests of the institution have been served and not just the interests of a few.

29. Phase II: Decision Making 7. In silence reflect and then listen to viewpoints. To ensure that the Spirit has guided the discussion and to promote the voice of any reservations or opposition, a quiet time of reflection should be offered during which group members consider the discussion in light of the faith tradition and personal conviction. Consider the following reflective questions: –Have I listened to the facts and appreciated the viewpoints of others? –Have I opened myself to the workings of the Spirit? –Have I sought the good of the entire ministry and then the particular good of others? Has input been elicited from all decision makers?

30. Phase II: Decision Making 8. Gain consensus on decision. Invite all members to express which option should be pursued and why. Discussion should be held until every member has had an opportunity to voice an opinion. At the conclusion of the participatory decision making, estimate if a consensus exists, and if not, identify the points of disagreement and allow for additional conversation for clarification. If a consensus is reached, identify the values that will suffer because of the choice. Discuss how to mitigate the harms.

31. Phase III: Follow Through Assign accountabilities to specific persons for each component to be realized. Build a plan for monitoring and reporting with measurable outcomes. Build a communication plan for community of concern with key messages and methods. Build a plan that connects to the larger meaning and purpose.

32. Conclusion Case analysis –Formal—examine policy—systematically! –Informal—examine practices/culture Resource allocations –Applied uniformly –Open process—transparency –Clear who decides –Appeals process