Healthcare Executive - September/October 2013 - 48

Healthcare Management Ethics

What Drives an
Ethical Culture?
Jack Gilbert, EdD,
FACHE

Providing incentives, celebrating good
behavior go a long way.

In a 2010 ACHE survey on ethical
issues, some ACHE members surveyed
said they are often faced with challenges related to “ensuring that all
staff recognize ethics as an organizational priority” and “creating an environment where ethical issues are
openly addressed without fear.” Well,
members, welcome to the club.
These particular challenges pervade
healthcare but also organizational life
across many other industries. In a supplement—on whistle-blowing—to its
2011 biannual, cross-industry,
National Business Ethics Survey, the
Ethics Resource Center reported that
of the nearly half (45 percent) of
American workers who observed some
form of ethical misconduct, one in
three (65 percent) of those who witnessed misconduct did not report it,
and of those who did report misconduct, one in five (22 percent) experienced some form of retaliation. It will
come as no surprise then that the most
common reasons given for not reporting misconduct were: (1) nothing
would happen, (2) fear of retaliation,
(3) fear of no anonymity and (4) that
someone else would report it.
The fact is, creating a shift in culture
requires remarkable diligence, tenacity
and attention over time. It is work that is
never done, and the moment we take our

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Healthcare Executive
SEpT/OCT 2013

eye off the ball the organization begins to
drift back to old, often negative, habits.
Here is a chastening example. In 2006
on the 20th anniversary of the space
shuttle Challenger disaster and three
years after the shuttle Columbia disaster, Mike Mullane, a retired astronaut,
wrote in USA Today: “Columbia’s loss,
just like Challenger’s, wasn’t an accident
but rather a prediction. Cultural issues
within the agency allowed intense
schedule pressures … to overwhelm
warnings of serious design flaws. … In
fact, in some of its findings, the
Columbia Accident Investigation Board
could have plagiarized the Challenger
Rogers Commission report nearly word
for word.”
I frequently write about the tenets of a
just culture and the daily disciplines of
an ethical culture, but I often struggle
with what actions can make the biggest
difference in this fierce fight for doing
the right thing every day, everywhere in
the organization (which for our purposes is striving continually to bring
alive at work the vision, mission and
values of the organization). Over time,
I have landed on incentives as a critical
leverage point. I want to suggest that
the reason why lapses in doing the right
thing are tolerated is because of a significant misalignment of incentives and
good intentions.

Focus on Incentives
In a June 16 article in ABC News
Online, Donald Berwick, MD, made
the point that “Boards of trustees in
healthcare are oriented around top-line,
revenue goals. They celebrate the CEO
when the hospital is full instead of
rewarding business models that
improve patients’ care.”
Is that true where you work, where you
lead? Can we have the courage to ask to
be incentivized on value as much as on
financial performance and volume?
Can we each lead the shift to value by
asking to be incentivized for it? Even as
the challenge is made harder when current reimbursement models struggle to
do the same?
It is worth reiterating the obvious: The
NBES continues to show that, while
companies behave differently during
economic difficulties, when the decisions and behaviors of their leaders are
perceived by employees as resulting
from a heightened commitment to
ethics, then employees adopt a higher
standard of conduct for themselves.
And what about stakeholders other
than the organizations’ leaders:
employees at every level, clinicians
who practice medicine on patients
but who are not employees, affiliated
groups, etc? They, too, must be
incentivized to do the right thing.
That may sound crass; after all, they,
like healthcare leaders, are in the
healthcare field because their very
nature is to care for people and do
the right thing.
The idea is not crass, however. On
the contrary, incentivizing stakeholders to do the right thing, and having
clear, negative consequences for those
Healthcare Executive - September/October 2013

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