Law & Governance
Healthcare Institution Partnerships - the Ethical Perspective
Restructuring initiatives, involving healthcare institution partnerships, can create ethical dilemnas.
While ethical issues have always been a fundamental consideration in healthcare, the unprecedented "surge of restructuring involving partnerships, has crystallized its relevance. For denominational hospitals, Catholic hospitals in particular, it raises questions intrinsic to the nature and mission of the organizations themselves. I was fascinated by the opening sentence of a recent commentary in Linacre Quarterly (May 1996), the official journal of the National Federation of Catholic Physicians' Guilds, in which The Reverend Russell E. Smith, S.T.D., stated that "In the past three years, one of the most common consultation requests submitted to the Pope John Centre has been for assistance in the ethical assessment of proposed hospital partnerships between Catholic and non-Catholic providers." The topic of Reverend Smith's commentary was "Ethical Quandary -- Forming Hospital Partnerships."
This quandary is not limited to Catholic hospitals. The issues -- such as mission compatibility, community needs and social justice, institutional culture, consistent organizational and clinical practices, treatment of employees, disposition of assets -- to varying degrees confront every organization undergoing some form of partnership, whether a total merger or a consolidation of one or two departments. Susan Rubin and Laurie Zoloth-Dorfman, co-founders of Ethics Practice, a firm devoted to bioethics consultation, underscored this point in Modern Healthcare (August 1996), where they wrote "Healthcare consolidation raises ethical questions ... in raising these questions, we're not claiming that moves towards economies of scale, efficiency or prudent use of resources are inherently evil ... but are mergers, morals and medical goals consistent? ... the ethical questions that are present in all of them are whether consolidation is in the best interest of stakeholders and whether the proliferation of new corporate relationships are properly motivated."
These questions, and more, characterize the broad scope of ethical challenges on both macro (e.g., mission, policy issues) and micro (e.g., employee and clinical practice issues) levels. For the purpose of this commentary, however, I would like to pay particular attention to the questions pertaining to four core issues.
I. Mission Compatibility
The key ethical question is whether one hospital can retain its values (denominational, cultural, community, etc.) when it partners with another hospital that doesn't share them. Are they actively working toward the same end, or are they working at cross-purposes? Partnerships can be a way to enhance an organization's mission. But, how do you blend each partner's mission to achieve that goal? One effective strategy to address this dilemma is to create a new mission which includes the inherent values of both partners, and which defines what is expected from the partnership and what it hopes to gain. A blended mission acknowledges the validity of each partner's values, and holds that each institution may be strengthened by this diversity. This, in turn, provides a renewed framework and a common point of departure.
2. Differing Cultures
Institutions inevitably have differing ways of doing things, and these managerial and operational practices comprise the institution's unique culture. During a partnering process, differences between cultures present substantial ethical challenges, including the potential undermining of each organization's cultural strengths. As you try to merge or co-ordinate these approaches, how do you accommodate those aspects where there are differences in philosophies and practices? Anthony F. Bono and James L. Bowditch in their book The Human Side of Mergers & Acquisitions (Jossey-Bass Publishers 1989) suggest that the key to managing cultural integration in partnership is to carefully diagnose the culture at the two institutions. What are the organizations' values? What is the managerial culture? What are the rites, rituals and myths? Based on this assessment, an effective plan addressing cultural integration can be formulated.
Whatever it is that defines a community - population focus, denominational, cultural, geographic - the ethical questions pertaining to hospital partnerships revolve around appropriateness of service, access and comprehensiveness, and the accountability of the new organization to the community served. How do you balance the board, for example, to ensure both communities are represented? Are the consumers in the community being served, properly represented in the governance structure? I suppose you can say that these are all issues any organization has to face on its own, but they are amplified when you look at partnerships. Certainly, where a full merger occurs, there are ethical issues around the disposition of foundation assets.
4. Employee Issues
Financial pressures and partnerships often lead to reductions in staffing and other job changes and, needless to say, employees deserve to be treated with fairness and integrity. Moreover, there are usually tremendous feelings of apprehension and thinking in the extreme. This may be exacerbated by the fact that staff may have chosen to work in a particular hospital because of its focus and reputation. The complexities are also heightened by the inherent alterations in working relationships and collective bargaining arrangements. A human resource strategy, therefore, is essential to address the myriad of challenges and associated ethical issues that partnerships pose in the work environment, including fair treatment, justice and even-handedness. An essential component of this strategy is to provide as much information as possible, particularly in a merger situation. Poor communication is not only bad strategy, but also is poor ethical practice in these circumstances.
It is difficult, of course, to totally prepare for all of the transitions and tensions that accompany a partnership. What is important, however, is to be aware that these issues exist and, therefore, must be addressed. The keys in dealing with these issues are (i) to recognize and understand them; (ii) to become aware of other experiences and how they were handled; (iii) to deal with the issues; and, most important (iv) to maintain constant communication with all stakeholders. In the final analysis, a partnership is a human process. Therefore, a strong focus on ethical issues supported by sound organizational mechanisms (e.g., staff ethicist), is essential to a successful outcome. Guiding principles, a human resource strategy, a communication/ information sharing plan, a sensitive cultural integration initiative, and a dedicated effort to create a "partner-friendly" environment, will also go a long way.
Joseph Mapa, FACHE, is
Executive Vice-President & Chief Operating Officer Mount Sinai Hospital
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