Formal Analysis of Organizational Policy Philip Boyle, Ph.D. Vice President, Mission & Ethics

1. Formal Analysis of Organizational Policy Philip Boyle, Ph.D. Vice President, Mission & Ethics www.CHE.ORG/ETHICS

2. Policy & Moral Agency Expresses will of organization How to examine policy from an OE perspective Values-based Decision-making The Case of Resources

3. How to study organizations Rational systems Formal—examines policies Natural systems Informal—examines real practices

5. 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

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

7. Case: The recruit Jane, environmental services employee for 30 days Tells Alice, the mission leader she will receive LPN in 6 months Jane likes her co-workers Jane applies to be a nurses aid RN recruiter states there have been exceptions to the policy that prohibits new employees from changing positions until the 90-day probationary period has been completed. Alice thinks there is a problem, but she is unsure how to name it.

8. Case: The recruit What kind of problem is this? Whose problem is this? Why make policy?

9. Phase I: Preparation • Number of persons/groups impacted • Duration of the impact • Depth or weight of impact • Closeness to Core Values • Degree of complexity • Past commitments • Relationship to strategic direction

10. 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?

11. Phase II: Decision Making • Identify question • Question identification • Is decision-making group clear about scope of authority?

12. Phase II: Decision Making 2. Determine primary and secondary communities of concern and their interests. • Determine manner and degree to which interests will be affected positively and/or negatively. • Special consideration should be given to those who are poor and vulnerable.

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

14. 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. • Identify the major consequences of this dignity trade-off in terms of individuals and groups.

15. Phase II: Decision Making 5. Establish priorities among commitments and values. • List moral commitments and values that deserve priority • Provide the rationale for why it is a priority.

16. 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.

17. Phase II: Decision Making 7. In silence reflect and then listen to viewpoints. • 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?

18. Phase II: Decision Making 8. Gain consensus on decision. • Invite all members to express which option should be pursued and why. • 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.

19. 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.

20. Summary of New Recruit • Policy expresses the moral agency of the organization so it is not for any one employees to decide to dismiss it. • Policy should address if exceptions are permitted and who decides

21. Why is resource allocation a key ETHICAL issue for organizations? • Expresses the moral character of organization • Policies proposed by management, approved by board, carried out by colleagues • Happenstance or intentional • Different goals • Cost containment, appropriate care

22. Done everywhere • Triage • Admission & transfer • Futility • Purchasing • Practice parameters • Formulary • Staffing patterns • Equipment

23. Different ways of allocating • First come, first serve • presupposes access to info • Clinical criteria or appropriateness • Neediest/worst off • 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

24. Length of Stay Case • 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.

25. Length of Stay Case • 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.

26. 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.

27. VBDM • I. Preparation • II. Decision making • What are the issues • Who is affected? • What info is needed? • What values should guide • What are options? • Which option is preferable? • Follow through

28. Considerations for LOS policy • What is missing? • “Who” is missing? • What are formal considerations?

29. 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

30. 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.

31. Writing the Policy • Clarity • Goals and Purpose • Values • Definitions • Process • Authority

32. Other Considerations • Is there “buy-in”? • Will the policy be followed? • Is it publicly defensible? • How does it treat unique cases?

33. Summary: Formal Analysis of Resource Allocation • Are the definitions clear? • Is it clear about who should decide? How decisions are made? • Are there checks and balances? • Is there room for exceptions? • How are exceptions addressed or appealed?