Informal Analysis In Organizational Ethics Philip Boyle, Ph.D. Vice President, Mission & Ethics

1. Informal Analysis In Organizational Ethics Philip Boyle, Ph.D. Vice President, Mission & Ethics www.CHE.ORG/ETHICS

2. Goals for today’s conversation • How to identity, study, and address organizational culture and behavior? • Medical sociology • VOTER method • Gaps between policy & practice • Professional biases

3. How to think about organizations Rational systems Formal—examines policies Natural systems Informal—examines real practices Open systems External systems—examines liability, laws, regulations, etc.

4. Organizational Culture & Behavior • Culture/ Organizational personality • “How we do things around here” • Culture is the glue of the organization • Values and beliefs of all participants and includes the internal and external interpretation of those beliefs • Informal unstated ways of acting • Difference between policy and actual practice

5. Organizational Culture & Behavior • Culture/ Organizational personality • Medical/ health care sociology • Practices not policy/ VOTER Method • Gap between policy and practice • Heuristic biases • Common biases • Profession specific biases

6. Medical Sociology“Then There Was One: The unraveling of Catholic health care” Dan Sulmasy, America March 16, 2009 1. The marketplace is a harsh environment for faith-based institutions. 2. Catholic philanthropy is weak. 3. Catholics operate under outdated institutional assumptions 4. Catholics are opting for secular values. 5. Ecclesiastical culture can be enervating 6. Catholic institutions often have poor political connections

7. Organizational Sociology Enron: The Smartest Guys in the Room All the Devils are Here, Bethany Spellman and Joe Nocera Hospital, Julie Salaman White Coat, Black Hat, Carl Elliott All the Popes Men, John Allen

8. Practice not policyCase: Death in the nursing home How and why do you think this practice/ritual came about? What values does this practice support? What are the unspoken rules? What does this practice say about: Death? Afterlife? Community?

10. VOTER Don Browning, A Fundamental Practical Theology • Exploring practices or situations in groups: • How do we see more than first meets the eye? • How do we recognize the complexity or the "thickness" of a practice? • How do we see what is being proclaimed by our actions and decisions? • How do we grapple with the theology that is "embedded" in what we do?

11. VOTER • Vision: Theological vision of practice? • Obligations: Protecting residents? • Tendencies: Calming fears? • Environment: Easy loading? • Rules: Don’t send messages of death?

12. Gap between Policy & Practice • 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. • 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. • 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.

13. Informal allocation • Intensive Care-Robert Zussman • Allocation methods • “Squeaky wheel” • Cuddly kids • Professional reciprocity • Personal identification

14. 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

15. Resource allocation Analysis of informal activities • 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?

16. Moral psychology: The Risks • “Ethical Leadership and the Psychology of Leadership” Messick and Bazerman • Wendy Carlton, In our Professional Opinion • Charles Bosk, Forgive and Remember • Danial Kahneman and Amos Tversky, Judgment under Uncertainty • Michael Davis, “The Challenger Disaster” • Jerome Groopman How Doctors Think • http://www.newyorker.com/reporting/2007/01/29/070129fa_fact_groopman • James Steward, Blind Eye: How the Medical Establishment Let a Doctor Get Away With Murder.

17. Decision Making Errors & Biases

18. Name the moral risks • Chief Medical Officer • Chief Nursing Officer • Chief Financial Officer • Chief Information Officer • Chief Mission Officer

19. Moral risks • Chief Medical Officer • Do not harm • Chief Nursing Officer • Patient Advocacy • Chief Financial Officer • No margin no mission • Chief Information Officer • Security • Chief Mission Officer • Prophet, “corrector-in-chief”

20. Conclusion • Culture/ Organizational personality • Medical/ health care sociology • Practices not policy/ VOTER Method • Gap between policy and practice • Heuristic biases • Common biases • Profession specific biases