Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times

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Ethics and Trusteeship for Health CareHospital
Board Service in Turbulent Times

• The slides presented here are drawn from a
  research project conducted by
• The Hastings Center
• and
• The New York Academy of Medicine

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Project Staff

• Bruce Jennings MA, Project Co-Director (The
  Hastings Center)
• Alan Fleischman MD, Project Co-Director (The New
  York Academy of Medicine)
• Bradford H. Gray PhD (New York Academy of
  Medicine)
• Virginia Ashby Sharpe PhD (Hastings Center)
• Linda Weiss PhD (New York Academy of Medicine)

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Project Task Force

• William N. Hubbard, Jr., M.D., University of
  Michigan, Chair
• Vincent Antonelli, M.A., The New York Academy of
  Medicine
• Jeremiah A. Barondess, M.D., The New York Academy
  of Medicine
• Henry Betts, M.D., Rehabilitation Institute of
  Chicago
• Irwin Birnbaum, J.D., Yale University
• Stanley Brezenoff, Maimonides Medical Center
• Gerard Carrino, MPH, The New York Academy of
  Medicine

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Project Task Force contd.

• Edward J. Connors, MHA, Connors/Roberts
  Associates
• Strachan Donnelley, Ph.D., The Hastings Center
• Charles J. Dougherty, Ph.D., Creighton University
• Joseph J. Fins, M.D., The New York and
  Presbyterian Hospital Cornell Campus
• Alan R. Fleischman, M.D., The New York Academy of
  Medicine

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Project Task Force contd.

• Livingston S. Francis, Livingston S. Francis
  Associates
• Harvey J. Goldschmid, LL.B., Columbia University
• Bradford H. Gray, Ph.D., The New York Academy of
  Medicine
• Bruce Jennings, The Hastings Center
• Anthony Kovner, New York University

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Project Task Force contd.

• Patricia Levinson, Trustee, Mt. Sinai Hospital,
  New York
• Paula Lowest, J.D., Weil, Gotschal and Manges
• William F. May, Ph.D., Southern Methodist
  University
• Richard L. Menschel, The Goldman Sachs Group,
  L.P.
• Linda Miller, Volunteer Trustees of
  Not-for-Profit Hospitals
• Ira Millstein, LL.B., Weil, Gotshal and Manges
• Mary Pittman, Dr. P.H., The American Hospital
  Association
• Kenneth Raske, Greater New York Hospital
  Association

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Project Task Force contd.

• Paul Rulison, Healthcare Trustees of New York
  State
• David Seay, JD, United Hospital Fund
• Virginia A. Sharpe, Ph.D., The Hastings Center
• David H. Smith, Ph.D., Indiana University
• William C. Stubing, The Greenwall Foundation
• Susan Waldman, Esq., Greater New York Hospital
  Association
• Linda Weiss, Ph.D., The New York Academy of
  Medicine

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The Ethics and Trusteeship for Health Care
Project was made possible by a grant fromThe
Greenwall Foundation

• For further information contact
• Bruce Jennings
• The Hastings Center
• Garrison, New York 10524
• 845-424-4040
• Jennings_at_thehastingscenter.org

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Ethical Principles of Not-for-Profit Hospital
Trusteeship
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The Uses of Ethical Principles

• Principles apply to patterns of conduct in the
  performance of a role
• Parallel virtues, which apply to moral agents
• Derive from the basic human and social ends
  served by a role

• Principles state general moral duties
• Complex roles usually encompass more than one
  principle
• Principles may conflict
• Principles provide guidance, not absolute answers

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Applying Ethical Principles

• Principles are not static
• Principles need to be applied to specific
  circumstances
• Principles may conflict in given circumstances

• Moral values and ends are plural, so principles
  may point in more than one direction
• Principles require interpretation

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Ethical Principles of Trusteeship
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Principle of Fidelity to Mission

• Trustees should use their authority and best
  efforts justly to promote the integrity and
  fulfillment of the mission of the not-for-profit
  organization, and to keep that mission alive by
  interpreting its meaning over time in light of
  changing circumstances.

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Principle of Service to Patients and the Care of
the Sick

• Trustees should ensure that high quality health
  care is provided to patients in an effective and
  ethically appropriate manner.

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Principle of Service to the Community

• Trustees should govern hospital policy and deploy
  hospital resources in ways that enhance health
  and quality of life in the broader community that
  the hospital serves.

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Principle of Service and Stewardship to the
Institution

• Trustees should sustain and enhance the integrity
  of the hospital as an institution, as an
  effective organization for the delivery of high
  quality health care services, and as a moral
  community of caregiving.

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TRUSTEES VIEWS OF THEIR ROLES AND ETHICAL ISSUES
THEREIN FINDINGS FROM AND EMPIRICAL STUDY

• Bradford H. Gray, Ph.D.
• Linda Weiss, Ph.D.
• The New York Academy of Medicine

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Purpose of Project Learn How Hospital Trustees
View Their Role

• To identify ethical issues with which trustees
  are dealing
• To see whether trustees themselves see ethical
  issues in their activities
• Study is exploratory

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Research Methods

• 2 Samples of Hospitals
• 16 in Greater New York, including SW Connecticut.
  Random and Diverse
• 6 elsewhere that have considered for-profit sale
  or conversion

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Research Methods

• Interviews at each hospital with CEOs, Chairs,
  and three other trustees (finance, clinical care,
  community)
• Total of 98 interviews at 22 institutions
• Data collected 1998 and early 1999

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Ways of Learning AboutTrustees and Ethics

• Asked how they view the responsibilities of
  trustees
• Asked whether their board has dealt with ethical
  issues in recent years
• Asked to discuss two major issues their board had
  dealt with in past year

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How Trustee Responsibilities Are Defined (N98)

• Oversight (91)
• Board/CEO Relationships (45)
• Policy Making (16)
• Hospitals Charitable Role (7)
• Fundraising (7)
• Trustees as Representatives (6)
• Advocates for institutions (5)

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How Trustee Responsibilities Are Defined (N98)

• Oversight (91)
• Financial, fiduciary responsibility, stewardship
  (43)
• References to community (36)
• References to quality (32)
• References to mission (28)
• Seeing that policies are followed or goals met
  (10)
• Legal responsibilities (8)
• Responsible for everything (20)
• References to ethics (3)

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How Oversight Responsibilities to Community
Were Described

• Trustees have a fiduciary responsibility to make
  sure resources given to the hospital are used
  properly. We represent the community in assuming
  this responsibility. (Trustee, urban hospital)
• We hold the hospital in trust for the community
  
• (Chair, community hospital)
• We have a responsibility to the community to
  maintain the hospital so that it can effectively
  meet the needs of the community. If the hospital
  isnt strong, then its not doing its job for the
  community. (Chair, urban hospital)

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How Oversight Responsibilities Regarding
Mission Were Described

• Trustees are to support and uphold the mission
  of the institution. To make sure we are
  following what the mission is and doing it in a
  way that is financially responsible. (CEO,
  teaching hospital)
• to ensure that the mission is carried out in a
  compassionate manner. (Trustee, teaching
  hospital)
• to develop and ratify the mission for the
  institution and to oversee the fulfillment of the
  mission (CEO, community hospital)

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How Ethics Were Mentioned Regarding Trustees
Oversight Responsibilities

• Trustees should ensure that the hospital
  provides ethical and appropriate services
  (Chair, urban hospital)
• Trustees should make sure the hospital is
  fiscally and socially responsible (Trustee,
  major teaching hospital)

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The Broad View of TrusteesOversight
Responsibilities

• Well of course, ultimately were responsible
  for everything that happens at the institution.
  As a practical matter, the trustees primary
  responsibility is to ensure that to the best of
  his ability his or her ability that the
  systems and procedures are in place to ensure
  that the care delivered is of the highest quality
  and that it is delivered in a financially
  responsible manner. And much flows from that
  (Chair, teaching hospital)

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How Trustee Responsibilities Are Defined (contd.)

• Policy Making (16)
• Setting goals and policies (16)
• Defining mission (2)
• Making resource allocation decisions (12)
• Strategic planning (12)

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How Trustee Responsibilities Are Defined (contd.)

• Board/CEO Relationship (45)
• Oversight (32)
• Hire and Fire (12)
• Supporting management (10)

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How Responsibilities in RelationTo CEO Were
Described

• The boards job is to select the CEO and
  monitor his performance, to ratify his decisions,
  change his mind, or replace him. If too much is
  done by trustees regarding running the
  organization, it brings mediocrity. (Trustee,
  urban teaching hospital)
• Were not running the hospital. Were setting
  the board policy under which people that we chose
  are running the hospital. If we get unhappy with
  the way the hospital is run, then we get a new
  CEO. (Chair, teaching hospital)

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How Trustee Responsibilities Are Defined (contd.)

• Hospitals Charitable Role (7)
• Trustees as Representatives (6)
• Fundraising (7)
• Advocates for institution (5)

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Trustees Identification of Ethical Issues

• The Question We Asked
• Of the issues your board has considered in
  recent years, are there any you think of as
  ethical issues?
• Most common response?

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Ethical Issues Identified by Trustees

• Ethics of Trusteeship
• Conflict of Interest (13)
• Board Composition (2)

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Ethics in Trusteeship

• Patient-related issues (39)
• Care of terminally ill (8)
• Abortion, reproductive services (6)
• Patient Rights (e.g. privacy) (2)
• Hospital ethics committee (8)
• Patient care incidents (17)

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Ethics in Trusteeship (contd.)

• Mission-Related Issues (23)
• Decision whether to stay in the city or relocate
• Decisions regarding availability of specialized
  services that meet the needs of the community
• Decision whether to help nearby struggling
  institutions
• Decisions whether to permit two standard of care
  for the rich and poor within the hospital

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Ethics in Trusteeship (contd.)

• Mission-Related Issues (contd.)
• Making sure that the hospital is not turning away
  patients that need help
• Tensions between commitment to the hospital
  versus commitment to the community in trying to
  assure financial soundness of the institution
• Trying to represent fairly the hospitals
  different constituencies regardless of ones bias
  or connections

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Ethics in Trusteeship (contd.)

• Mission-Related Issues (contd.)
• Deciding to close facilities that were losing
  money or in need of major capital infusions
• Deciding whether to sell to a for-profit
  purchaser
• Resource allocation decisions

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Mission-Related Ethical Issuesin Merger/Sale
Context

• It looks like we will be doing a full asset
  merger with two other hospitals. Mission
  compatibility is our primary concern we exist to
  serve a very needy population. (CEO, urban
  community hospital)
• Ethics are implicitly discussed in terms of our
  commitment to the community and how to maintain
  it. Questions include who is going to own the
  hospital and how to protect community control of
  the institution. (CEO, urban community hospital)

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Mission-Related Ethical Issuesin Merger/Sale
Context (contd.)

• Ethical issues? I think of them primarily as
  survival issues. But maybe ethical is what is
  our responsibility to the community? That was
  certainly our decision to go ahead with the deal
  to help another hospital. (Chair, urban
  community hospital)

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Mission-Related Ethical Issuesin Merger/Sale
Context (contd.)

• The merger with a Catholic hospital presented a
  number of ethical issues. The agreement calls
  for us not to be governed by the ethical and
  religious directives of the Catholic Church. But
  there was a lot of discussion about how the
  community would respond to a relationship with a
  Catholic facility and whether there would be any
  indirect influence to do things that we would not
  normally do or restrict things that we would not
  normally restrict. And what it will mean for us
  in the long run and the short run. (CEO,
  non-urban community hospital)

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Ethics in Trusteeship (contd.)

• Business-Related Issues (29)
• Dangers of additional debt
• How admissions office should handle patient who
  arrive without a proper referral from a physician
• How to handle downsizing and layoffs
• Extent of salary differences at top and bottom

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Ethics in Trusteeship (contd.)

• Business-Related Issues (contd.)
• Deciding whether over-payments identified in the
  hospitals compliance program should be returned
  to payer
• Having a strong corporate compliance program to
  assure that the institution does not violate
  regulations and law

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The Global View of Ethics

• Probably every issue we face has an ethical
  aspect. If we werent cognizant of the fact that
  we represent the community and the delivery of
  health care needs that it expects and requires,
  then our ethical responsibility would require
  itIf we make decisions improperly or without
  proper information in effect weve hurt these
  people in terms of access, quality, and comfort
  ability of receiving care, and then ethically
  have not begun to do our responsibility as
  trustees of health. (Trustee, Non-urban
  community hospital)

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The Global View of Ethics

• I think every issue we deal with is an
  ethical issue. If youre adopting a budget,
  thats and ethical issue. How much money do you
  allocate to the emergency room? How much money
  is available for unreimbursed care? How do you
  take care of the uninsured? When do you decide
  youre going to let some people go, those are
  ethical decisions. I think its hard to separate
  out ethics from any decision facing a board today
  in any hospital. Were literally dealing with
  the most fundamental ethical issues that we have.
  Care for the sick and needy. I dont know how
  you can get more fundamental than that. There
  are other ethical issues that have to be
  addressed. Do you treat people differently
  because they can pay? Do you treat people
  differently because theyre on Medicaid as
  opposed to private insurance? I can tell you
  from the very beginning, this hospital has
  always been committed to one level of care
  (Trustee, urban community hospital)

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Core Governance Responsibilities

• Provide Direction for the Organization
• Vision
• Mission
• Values
• Goals
• Initiative (strategies)
• Policies

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Core Governance Responsibilities

• Enhance Assets of Organization
• Financial
• Human
• Reputation
• Facilities

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Core Governance Responsibilities

• Appoint, Support Evaluate the CEO
• Hold accountable for performance
• Board Chair/CEO Partnership
• Succession Planning

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Core Governance Responsibilities

• Assess Improve the Quality of Services
• Clinical Support Services
• Clinical Appropriateness Outcomes
• Contemporary Standards
• Environment of Continuous Quality Improvement

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Core Governance Responsibilities

• Take into account the needs of the population
  served unmet community needs the needs,
  perceptions viewpoints of key stakeholders

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Core Governance Responsibilities

• Be publicly accountable for the financial
  clinical performance of the organization

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Essentials for Governance Effectiveness

• Time commitment of all members
• Requisite knowledge
• Learning curve is continuous steep
• Requires continuous education

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Essentials for Governance Effectiveness

• Appropriate size composition
• Strategic orientation behavior
• Reliable valid governance information system
• Processes that achieve timely informed board
  decisions