TO BOARD ROOM
By Sara L. Goldberger, ACSW
Chairperson of the Patients' Rights and Organizational Ethics Committee
Catherine R. Seeley, MA
Director of Bereavement Services
Calvary Hospital, Bronx, NY
The Joint Commission on Accreditation on Healthcare Organizations (JCAHO) commanded attention to institutional ethics in 1991 by requiring a “functional mechanism for the consideration of ethical issues arising in the care of patients.” Four years later, a larger lens of scrutiny was fitted onto accreditation surveys: marketing, admission, transfer, discharge, billing practices, contracts, educational institutions, payers, staff and a formalized code of ethical behavior were pulled into focus, composing the more complete picture of “Patient Rights and Organizational Ethics.”
1. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) is a private nonprofit, quasi-official accrediting organization that represents five professional groups: the American Medical Association, the American Hospital Association, the American College of Surgeons, and the American Dental Association. It accredits 5,300 hospitals and 6,000 nursing homes. Accreditation for helathcare institutions is required for reimbursement from government programs, including Medicare and Medicaid.While JCAHO has been catalytic in this more comprehensive approach to ethics, administrators, indeed, boards of institutions and agencies necessarily must be committed to and proactive in endorsing integrated ethics. Not the “hobby” of a few interested persons, but the responsibility of all associated with the organization, the success of a strong integrated ethics program depends on interest and involvement on all levels.2. JCAHO, “Patient Rights,” 1992 Accreditation Manual for Hospitals (Chicago, IL.: JCAHO, 1992): 103-105.
3. JCAHO, “Standards for Organizational Ethics,” in the section “Patients Rights and Organizational Ethics,” 1996 Comprehensive Manual for Hospitals (Chicago, IL.: JCAHO, 1996): 95-97.
As intended, this Organizational Ethics Statement reaches into the patient’s room, the boiler room and the board room. It insists on vigilance regarding conflicts of interest, allocation of resources, equality and fidelity: cross current issues that float between clinical and organizational ethics every day. It translates theoretical concepts into practical applications, assisting individuals in all departments to acquire or strengthen “the habitual disposition of acting well.”
Experience has shown that ethical issues exist across a continuum and often move from patient’s rights issues to broader issues encompassing the ethics of an entire organization. Cases that originate in the purview of a patient rights committee often have several embedded questions that are more organizational in nature and visa versa. Committees must be able to move from the general to the specific and from “case to cause”. For these reasons, the authors suggest an integrated approach to ethics that can address both the clinical and organizational issues that emerge. This integrated approach can help to maintain the balance between compassionate duty and fiduciary duty.
As we have gained more experience with the range of issues presented in actual practice, we have learned that the straight lines of demarcation once perceived as separating clinical ethics from organizational ethics actually arc one into the other. This confluence protects the patient, maintains the integrity of the institution, and transforms a workforce into a community of concern. Because we have seen the dissolution of such boundaries, our two separate committees now meet as one. This insures that all facets in the prism of quality care are viewed in the light of the overall mission of the institution.
The mission of the institution, however, remains incomplete in these times if it does not include advocacy for its patients. While managed care is laudable for its attack on overutilization, it remains morally suspect in its aggressive practice of underservice. The true moral weight of a patient’s condition is entrusted to and rests in the care of the provider. Without institutional advocacy on behalf of that patient, the market will surely trump the mission. An integrated ethics program involves everyone in making sure that never happens.
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