DEVELOPING AN ORGANIZATIONAL PHILOSOPHY
The starting point for an organization to prevent and, if necessary, solve ethical problems is its philosophy. The statement of philosophy identifies values and principles reflecting the moral right and wrong for the organization, thus distinguishing the acceptable from the unacceptable. It is helpful if the philosophy statement is sufficiently precise that performance in achieving it can be measured. At minimum, the statement of philosophy must be consistent with the law.
The statement of philosophy is different from the mission statement and should be developed separately. The philosophy statement provides a context for the mission statement; the mission statement is subordinate to it. Some organizations include references to values in their mission statements. A mission statement that “the corporation owns and operates hospitals to provide care for the sick and injured” provides no information about the moral context of care. A mission statement that “the hospital provides care for the sick and injured in the context of humanitarian principles” is imprecise but provides a clearer values or moral context than the first.
Health services organizations with no specific, written philosophy nonetheless have an identifiable de facto or operational philosophy. The aggregate decisions and actions taken by the governing body and management reflect implicit, if ill-defined, philosophical bases. Management actions may be contradictory or inconsistent, and this suggests another negative aspect of not determining prospectively a comprehensive organizational philosophy. This lack of continuity and consistency will lead to incompatible, even contradictory, policies, procedures, and rules. The effect is diminished efficiency. Equally important is that the mixed, even contradictory messages that staff members receive will confuse and frustrate them, with a resulting decline in patient focus and quality.
The importance of identified and shared values in organizations is now widely understood, if less frequently operationalized. In the early 1980s, however, it was a new concept, one that was synthesized by Peters and Waterman in their study of successful American corporations.1 The quote attributed to IBM’s former president Thomas J. Watson, Jr., is instructive: “The basic philosophy of an organization has far more to do with its achievements than do technological or economic resources, organizational structure, innovation, and timing.” That statement’s context was the focus on customer service so important to IBM’s reputation and financial success at the time. If consumers and service are important to IBM, which has many characteristics of a products-based organization, consider the importance of customers and service in healthcare. The centrality of shared values is shown in Figure 5, the 7-S Framework, developed by McKinsey & Company.
Deal and Kennedy2 also identified the characteristics of successful companies:
• They stand for something—that is, they have a clear and explicit philosophy about how they aim to conduct their business.
• Management pays a great deal of attention to shaping and fine-tuning these values to conform to the economic and business environment of the company and to communicating them to the organization.
• These values are known and shared by all the people who work for the company—from the production worker right through to the ranks of senior management.
Building on the importance of shared values or philosophy that make up a culture, Deal and Kennedy3 identified the essential elements of a culture: 1) understanding and fitting into the business environment—the single greatest influence in shaping a corporate culture, 2) values—the basic concepts and beliefs of an organization, 3) heroes who personify the culture’s values and are role models for employees, 4) rites and rituals that show employees the kind of behavior expected of them, 5) ceremonies that provide visible and potent examples of what the company stands for, and 6) the cultural network—the primary (but informal) means of communication within an organization that is the “carrier” of the corporate values and heroic mythology.
In further explaining corporate cultures, Kennedy4 noted the following:
Culture isn’t a single thing. It’s not a budget; it’s not a plan; it’s not the shape of a building. It is an integrated pattern of all the things that go on in an organization on a day-to-day basis. Each company has its own unique culture, values, and standards communicated internally by style, dress, expectations, and assumptions.
New people in the workplace find out what is expected of them because their peers take them aside and say, “Look, don’t wear jeans here. Come in to work on time, or you do this or that.” They lay out some of the unwritten rules of behavior that are required for entrance into your workplace. That’s how culture transmits itself to each new generation of persons. They don’t come in and invent a whole new style of organization. They come in and learn from those around them what’s going on in the organization and how they are expected to behave.
An organization’s values are inextricably linked to its culture. To transform the organization so that its culture is a living reflection of values that facilitate the mission and vision, management must know which values are present in the culture. This presents somewhat of a chicken-and-egg situation. Regardless, management must biopsy the culture. This can be compared to a financial audit, except it is the organization’s values that are being audited. Direct measures such as observation, staff surveys, exit interviews of departing staff members, and focus groups can be used. Proxy measures of culture include patient satisfaction surveys and service area surveys. Regardless of how it is done, however, management cannot effectively transform the organization’s culture until its present content and course are known.
Figure 5. The McKinsey 7-S Framework.
(From McKinsey & Company, Inc. Reprinted by permission.)
The barriers to establishing strong corporate cultures in any organization are a particular problem in health services organizations. For hospitals, barriers include:5
• Hospitals must serve diverse medical needs of heterogeneous populations.
• The number of external variables (forces outside the organization that affect it) is much greater for hospitals than it is in ordinary business enterprise.
• Hospital outcomes are difficult to define and to measure.
• It is difficult to nurture the keen proprietary sense of individual endeavors among leadership and management staff at all levels.
• Hospital board members are not active participants in its culture.
• Hospital physicians are a subculture, and peer acceptance and recognition, participation in professional activities, and stature based on professional contribution and expertise are more important than the rewards of belonging to a particular hospital.
• Elaborate peer reward systems in nursing are complicated by a deep search for professional identity.
• Support staff and especially allied medical personnel increasingly tend to have a professional identification independent of the hospital.
• Another special subculture in hospitals is the administrators, who are caught between the role of facilitating the delivery of medical care and that of running a cost-effective “business”; as a result, they often isolate themselves from other subcultures.
Beyond these factors, and implicit in them, is the need for managers to view their relationships with staff and patients in a consistent fashion. Paying lip service to the organization’s avowed goal of patient care but in fact focusing on economic or other nonpatient considerations is a contradiction that will not be lost on staff, who will respond to real incentives rather than platitudes. Not only must the decisions and actions of leaders be consistent with organizational values, but staff must perceive that they are consistent, lest the leader be judged a hypocrite. If values and how they are understood evolve over time, managers must solicit feedback to identify any disconnect between what they are saying and what employees are hearing.6
Management must know and understand the culture and values in its organization. Just as important, management must know how the culture and values mesh with or diverge from those the organization wishes to develop. The organization can mold a culture, but it can move neither faster than nor in directions that are opposed to or misunderstood by internal stakeholders. This congruence is critical. The organization’s philosophy and derivative vision and mission statements are the primary points of reference for its corporate culture and subordinated activities. All efforts to develop excellence are a function of these statements.
A logic is evident in the link between the strength of a culture and organizational performance. The first piece of logic is that of goal alignment—a strong culture causes staff to metaphorically march to the same drummer—the pheromone of the organization. Second, a strong culture aids in performance by creating an unusual level of motivation among staff—shared values and behaviors make staff feel good about working for an organization; the resulting commitment or loyalty makes them strive harder. Third, a strong culture aids in performance because it provides needed structure and controls without relying on a bureaucracy, which can diminish motivation and innovation.7
Closely linked to the concept of organizational philosophy and corporate culture is management’s view of the organization’s staff. McGregor’s Theories X and Y, Maslow’s hierarchy of needs, and the 14 points enumerated by W. Edwards Deming echo the importance of management’s view of its employees, which is likely to be similar to how patients are viewed by a health services organization. Dysfunction is rife in an organization that treats employees as adversaries or as a means to an end and distrusts them while it urges staff to treat patients with dignity and respect. Employees see the hypocrisy and respond negatively. Peters and Waterman8 sounded this theme, quoting Thomas J. Watson, Jr.: “IBM’s philosophy is largely contained in three simple beliefs. I want to begin with what I think is the most important: our respect for the individual. This is a simple concept, but in IBM it occupies a major portion of management time.”
Culture as Pheromone
The values of an organization are reflected in its culture. If they are positive, these values will bind the organization together. The resulting congruence of values will enhance operational and mission effectiveness.
Insects communicate, attract, and repel using pheromones. Bees and ants are the best-known organized insect societies that use unique pheromones to perform many of the tasks needed to survive and thrive. Bees are probably the most widely studied and best understood of organized insect societies.
In many ways, the api regina, or queen bee, is the bee colony. She is the center of attention and has a retinue of attendant bees whose sole task is to feed, groom, and support her work. The queen is critical to the hive; only she can lay the eggs that enable the colony to survive and thrive. But the queen bee performs another essential task; she binds the colony into an organized society. Each api regina emits a unique pheromone. This pheromone is spread throughout the hive by the movement of bees’ wings. It allows the bees to recognize the queen and one another. Guard bees at the entrance to the hive recognize those attempting to enter by their scent and know that they belong to the hive. The bees that come from another hive to “rob” a hive’s honey are driven away. When there is danger, the bees emit an alarm pheromone and the colony immediately acts to defend itself.
Worker bees newly emerged from the comb in which they develop from egg to larva to pupa perform nurse and housekeeping tasks for several days until they are strong enough to become field bees and forage for nectar. Young worker bees have very active wax glands. The liquid wax they secrete is used to build comb in the classic hexagonal shape. The queen lays her eggs in this comb. Other comb is used to store pollen, beebread, and the nectar that is processed into honey. When the honey is ready, the comb containing it is sealed with a wax cover. The natural antibacterial properties of honey allow it to be stored indefinitely.
Their tasks are instinctive; no control or direction is apparent. The average summer life expectancy of a worker bee is about 45 days. Thus, their development must occur in rapid order. When strong enough to fly, nurse and house bees become field bees who forage for nectar-producing flowers, bring the nectar to the hive in their honey stomachs, and add enzymes so that the minute amounts of nectar can be processed into the honey, which is food for the hive and so pleasing to human palates. In gathering nectar, bees pollinate the flowers of plants and trees that produce a wide variety of food for human consumption. About 30% of the U.S. food supply could not be produced without pollinating insects, especially the honeybee.
Of what relevance to the modern health services organization is the pheromone that binds a bee colony? Simply put, the organization’s value system is a metaphor for the queen’s pheromone. Health services organizations do not have an api regina (although some situations might suggest otherwise). But organizations do have a managerial hierarchy with similar characteristics. By their example, managers—especially those who are senior—exude a values pheromone. Those who work in the organization identify one another by their personal value systems—their personal ethic—and this ethic connects them with other staff and largely reflects the value system of the organization. A positive value system enables the organization (the colony) to thrive and produce the output that enables its success. In the case of honeybees, the honey will sustain the hive. In a health services organization, it is the delivery of patient care, for which the organization receives the revenue that enables it to thrive. A health services organization with high-quality services enjoys satisfied customers who return for treatment and recommend it to others.
Content of a Philosophy Statement
Organizational Content
The values and principles stated in an organization’s philosophy establish a moral framework for its vision and mission. The philosophy provides a context and operative values—it gives delivery of health services a life, a meaning—and recognizes that these values are unique and represent more than delivering a product or rendering a service. Policies, procedures, and rules are derived from the mission statement and make the organization operational. The approaches taken by health services organizations are varied. Typically, those that are faith based have a greater focus on values and ethical principles. The commitment to values and ethical principles is not, however, exclusive to faith-based organizations. The Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission) recognizes the importance of an ethics framework and identifies specific elements.9
Sutter Health is a large, West Coast health services system. Its values include honesty and integrity, excellence and quality, innovation, affordability, teamwork, compassion and caring, and community.10 Its mission, vision, and values are reproduced in Appendix A. These values reflect ethical principles and some of the virtues enunciated in Chapter 1.
Trinity Health is a faith-based health services system that provides services across the continuum, from acute to long-term care and hospice. It has the classic trilogy of mission, vision, and values. Core values include respect, social justice, compassion, care of the poor and underserved, and excellence.11 Trinity Health’s mission, core values, and vision statement are reproduced in Appendix A.
The George Washington University Medical Center includes a teaching hospital, schools of medicine, nursing, and public health, and a physician group practice. Its mission is teaching with creativity and dedication; healing with quality and compassion; and discovering with imagination and innovation. Its vision is to improve the health and well-being of our local, national, and global communities. The specific elements of the institution’s vision appear in Appendix A.12
Mountain View Regional Medical Center is a midsized hospital in Las Cruces, New Mexico. Its mission identifies a caring environment, its healthcare team, and service excellence. Stated values include safety, compassion, teamwork, and efficiency.13 The MountainView mission and values statements are reproduced in Appendix A.
Mayo Clinic is a large, multi-specialty group practice that operates hospitals and a medical school, conducts research, and engages in postgraduate medical education. Its primary value is “The needs of the patient come first.” Core principles include practice, education, research, mutual respect, commitment to quality, work atmosphere, societal commitment, and finances.14 Its mission, values, and principles are reproduced in Appendix A.
Sunrise Senior Living is a nonsectarian for-profit organization that provides a gamut of services to seniors. Its core values include passion, joy in service, stewardship, respect, and trust.15 Its mission, principles of service, and core values are reproduced in Appendix A.
Relationship with Patients
One cannot imagine a health services organization that does not identify its role vis-à-vis patients in the context of respect for persons, beneficence, nonmaleficence, and justice, as well as the virtues discussed in Chapter 1. These values mandate delivery of medical services to patients with respect and in a manner that enhances human dignity. Staff members must know their responsibilities and duties toward patients in this regard. Patients are the reason why the organization exists, and all efforts are directed at meeting patient needs by safely delivering high-quality services.
Williams and Donnelly16 asserted that accountability to the patient takes precedence over all other duties and relationships in health services organizations. They were pioneers when they had the temerity to assert that accountability to patients demanded that hospitals inform them if they had been harmed by medical misadventure. These views are mainstream today; in fact, the expectation is even broader. The Joint Commission requires that organizations provide information about unanticipated outcomes of care, treatment, and services to patients. Its standards spell out how licensed independent practitioners (typically, these are physicians) or their designees are involved when unanticipated events occur.17 This requirement continues to be controversial, if not as radical as in the 1980s. Informing patients and their families, as appropriate, of problems during treatment is the ethically (morally) right course. In addition, there is increasing evidence that informing patients and their families, as appropriate, about medical misadventures makes them less likely to seek legal redress because they believe the organization is being honest and that they are being treated fairly. However, this may not make believers of governing bodies, managers, and physicians. Intellectually, they may agree with the ethics of this degree of accountability, but many will react with measured skepticism because the legal system demands an adversarial approach. Apologies are being addressed in the states. In 2010, 12 states considered bills to make expressions of regret and the like inadmissible in court.18 This issue receives further attention in Chapter 8.
The economic hazards of implementing such a philosophy are significant, especially in organizations with a voluntary medical staff. Regrettably, the organization that becomes supportive of patients and disregards its physicians risks alienating the physicians, who provide its economic livelihood. The organization will likely have angry physicians. One answer to this seeming dilemma is to immerse physicians in the corporate culture, thus making its organizational philosophy and value system part of their perspective. Hence, physicians will see substandard clinical treatment as endangering the corporate culture and will work with the organization—to the ultimate benefit of the patient.
(Darr 54-63)
Darr, Kurt. Ethics in Health Services Management, 5th Edition. HPP, 7/2011. VitalBook file.
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