Wednesday, July 6, 2016

Bioethical Organizational Behavior - a Leadership Mandate

Thomas E. Catanzaro, DVM, MHA, LFACHE
Dipomate, American College of Healthcare Executives
CEO, Veterinary Consulting International

Bioethics is the study of typically controversial ethics brought about by advances in healthcare, biology, and medicine. It is also moral discernment as it relates to medical policy, practice, and research. Bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, and philosophy. It also includes the study of the more commonplace questions of values ("the ethics of the ordinary") which arise in organizational behavior, primary care and other branches of healthcare delivery.

I first published a review of bioethics in my 1998 text, Building the Successful Veterinary Practice: Programs & Procedures (Volume 2), Blackwell/Wiley & Sons Publishing.  In the USA, we consider ear crops, tail docks, and declaws to be examples of bioethical situations, and in Australia and New Zealand, as well as the USA and Canada, elective euthanasia, especially of unwanted litters, and cancer therapy decisions, are two common examples of a bioethical issue.  Then I read the cover story in Bloomberg Businessweek, "the Cheapest, Happiest Company in the World - where toilet paper - and ecstatic employees - can both be found in bulk - COSTCO!"  With Costco just breaking into the Australian market, this was a perspective awakening for me (I wrote the Organizational Behavior monograph about that time and put it into the VIN Bookstore).  The CEO of Costco attributes much of the company's financial and market success to treating its employees well. In fact, in 2013, the CEO of Costco wrote an open letter to Congress addressing the raising of the federal minimum wage, stating, "We know it is a lot more profitable in the long term to minimize employee turnover and maximize employee productivity, commitment, and loyalty."
Australia is looking for Costco to break the petrol duopoly of ever increasing prices, and very little is being said about workplace benefits, since there are so many already established in the Australian wage award and mandated benefit systems. But the article got me pondering about the morale management by the leadership in veterinary healthcare delivery; the value in treating staff members well and managing them in ethically responsible ways, while ensuring the bioethical decisions within the organizational behavior stay aligned to the Core Values, Standards of Care (SOC), and Mission Statement of the practice culture.

Very few observers would disagree that organizational culture, bioethical standards, and a safe/healthy work environment are essential in fulfilling one's ethical responsibilities to a healthcare delivery team. But while the "right" policies and procedures, and the "right" culture and work environment, may be in place to promote ethical treatment of staff members, it is the day-to-day bioethical management decisions and actions that determine whether managers and leaders are fulfilling their practice culture responsibilities to the staff members of the practice.

Creating a practice infrastructure that includes such things as a written Standards of Care is much easier than establishing an internal code of ethics and tracking metrics to ensure internal compliance by all providers (including specific procedures per 100 patients).  Making bioethical conduct the norm throughout the practice operations is a much more difficult task than tracking new metrics.  More than anything, managers and veterinarians who role model bioethical conduct in their treatment of staff members send a clear message about what is acceptable behavior in the practice. When staff members are treated with honesty, fairness, and respect, they are more likely in turn to treat patients, clients, vendors and peers in the same way, thus contributing to the practice success and reputation in the community and within business relationships.

Competent, bioethical clinical and ethical employment practices will make the practice a destination of choice for new staff members, who by the nature of this profession, are usually answering a 'calling' that is deep seeded within their own personal values. People want to work for ethical practices with leaders who inspire and challenge them in achieving high levels of bioethical performance. A practice culture where staff and leaders are treated ethically and expected to treat patients and clients within established bioethical standards, in a manner which attracts and retains a workforce, that has pride, and thus will enhance the image of the practice in the community.

When recruiting staff, it is sometimes tempting to oversell the practice, as well as its position in the community.  Staff pride speaks louder than anything the interviewer can say!  When making a job offer to a new candidate, it is a questionable practice to offer more compensation/benefits than what an existing staff member with tenure and experience in the practice is earning. Caution must be exercised to ensure equitable compensation, benefits, and support for all staff members.

When first interviewing the core nursing staff for the new Veterinary Teaching Hospital (VTH) at Roseworthy, in South Australia, I advertised the job(s) for experienced nursing staff (Certified Veterinary Technicians in Australia are Veterinary Nurses, Cert 4). During the interviews, I stated the wage and benefits in accordance with the established Australian Award system, and interviewed for attitude and aptitude toward team-based healthcare delivery.

When I selected first four, I set them to work on the four-phase Orientation & Training program. When they opened their first pay check, they found they were being paid well above the Australian Award, as well as almost double the established benefit package; they asked for an explanation. The answer was simple - I wanted to hire people who wanted to do the new, cutting edge, duties of a VTH nurse (which included student training and mentoring), not just earn more money or more benefits.

These four veterinary nurses then were tasked to hire next four, using the same techniques, and field test the four-phase Orientation & Training programs they had been evolving to be established as the Roseworthy VTH staff development program.
Point taken - hiring or promoting a staff member into a position, giving them clear expectations of duty zone responsibilities and accountabilities, and then failing to provide resources or the needed authority needed to meet the job expectations is unfair to both the staff member and the practice.

The stethoscope
Did I mention, each of those nurses received a personal stethoscope?  Did I tell you I asked them to pick their own color? Have I told you I consider a personal stethoscope an important message (ear wax control, etc.)? Actually it was a bioethical decision to re-enforce the concept of nurses doing primary care, with clients as well as with patients. I can tell you, it is rare to find a practice empowering their staff with this type of gesture.
Factoid - much has been written in literature and the media about sexual harassment, and yet those cases continue; bullying is now a major issue in Australia. In ethical practices, management has established a zero tolerance policy concerning sexual harassment, yet because we have had veterinary-centric culture for so long, bullying is allowed to continue by control-centered veterinarians.  In a bioethical practice culture, this is intolerable regardless of past paradigms.

In bioethical practices, retrospective performance appraisals have been replaced by quarterly prospective performance planning (title specific monograph, with forms and formats, are available in the VIN Bookstore).  The self-assessment used in performance planning is viewed as fair, honest, objective, timely, and focused on the scope of duty being performed.  Zone duty standards replace the traditional job descriptions, and outcome expectations for zone operations are kept within the duty standards.  With the three-column performance plan (competent, needs help, or ready to train others), self-assessment of below standard performance is therefore  not related to age, sex, nationality, health, or family issues which may be viewed as discriminatory.

The quarterly performance planning by individual staff members replaces those retrospective appraisals traditionally done by managers as bureaucratic necessities, and minimize the ethical and bioethical issues now faced by traditional systems that rate 1-10, excellent-outstanding-good-fair- etc.-etc.-etc..  In healthcare skills and delivery, competency is excellence - there are NOT levels of mediocrity.  Study after study in healthcare cultures show staff members want the recognition and feedback of their performance; anything else is unfair and bioethically damning!  The performance planning concept has proven to be far more constructive, since 95% of the healthcare workers will rate themselves tougher than their supervisors would; this allows much more "good news" and "positive feedback" in the performance planning process.

Effective managers know they need two-way communications within their healthcare delivery team(s). They know they need to seek opinions and ideas from staff members, encourage civil debate, and avoid the practice of listening only to those who agree with their position; these are bioethical observation points, since perspectives on effective listening are not mandated from legal parameters.

Savvy managers recognize that any threat to the status quo or existing stability of the practice, such as expansion of hours, changes in shift staffing, or even new hires, will have a direct impact on the perceived job security of individual staff members.  Zone coordinators need sufficient information to mobilize personal resources to plan or take action as needed. It is unfair to withhold information from existing staff members that may allow them to participate in brainstorming alternatives for the practice.

The practice leadership must not lose sight of the fact that staff satisfaction, loyalty, commitment, and productivity are in large part directly related to how the perceive they are treated as trusted team members by their "boss" - not primarily by organizational policies, procedures, or paradigms - which they .know are manifestations of the "boss's" or managers expectations. It is the day-to-day decisions embedded in routine functions that reflect bioethical treatment of the workforce, clients, patients, and community, which in turn reflects on the character of the leadership and, in turn, the character and image of the practice.

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