The ethics of organizational change in healthcare

Abstract

The article addresses the increasingly important issue of organizational ethics in healthcare. Assuming that the governance of organizational change consists of a seriousness of continuous choices and of objectives to be determined and achieved, a possible definition of this new discipline is then deepened, and its fields of application are identified. In the discussion therefore emerge the close link between ethical choice in organization and legality, passing through transparency and prevention of corruptive phenomena. After a focus on the strategic role played by the Medical Doctor of the healthcare management team, in conclusion, the need arises to support a strengthened supervisory and evaluation system and a culture of the ethical organizational choice of health managers, a rooting of the sense of identity and belonging to the healthcare organization and its mission by Professionals. Also governing this last aspect is the new challenge for the management of public healthcare enterprises. (www.actabiomedica.it)

One of the key characteristics of a dynamic public healthcare enterprise is organizational change, understood in all its possible meanings: proactive or adaptive, spontaneous or induced. The change is a phenomenon universally present in the experience of the organizations and this is more relevant in those healthcare characterized by a continuous search for quality, excellence and innovation.

We speak of “organizational change” when organizations modify their systems and organizational sub-systems to survive in contexts characterized by uncertainty and by the need for change through the innovative capacity of successful experiences (1).

Governing change in healthcare consist in making continuous choices consistent with short, medium and long-term goals achievement.

Ethics is considered a very ancient discipline, a valid definition was provided by Aristotle in the 4th century BC.: “Ethics is that branch of philosophy that studies the conduct of human beings and the criteria by which behavior and choices are evaluated”.

Therefore, as an organization (from the ancient Greek language: ὅργανον -organon- instrument) is a group of people formally and deliberately united (social unit) to achieve one or more common objectives, difficult to achieve individually, the health organization is characterized by the goal that it must achieve: an appropriate response to the health needs of the population it belongs to (art. 32 of Italian Constitution). The fields of application of organizational ethics are:

1. the ethics of financial management (to guarantee sustainability and equity of access),

2. transparency in management and in roles,

3. professional responsibility (both by health professionals and managers).

A practical and pragmatic definition was provided by the Ethics Committee for Clinical Practice of the Azienda ULSS 18 of Rovigo (2) in an official document: “Organizational Ethics consists of intentional use and discernment of values to guide managerial decisions that influence patient care and health practice, resulting from scientific and clinical changes in health care”.

What derives from this, for those who daily take care of the planning, management and administration of a complex health organization system, is that the organization is ethical as far as its mission consists in the creation of interfaces and models of patient-centered integration that guarantee the absolute continuity of assistance to the patient. However, it must also be ethical towards its Professionals by protecting them in two directions: creating organizational, structural, resources, procedural and relational conditions for working at the maximum level of safety and at the maximum of their abilities, and also in order to enhance their skills and vocations, being able in turn to derive their added value.

It is advisable for each Professional, in the face of an organizational choice or a formulation/revision of an organizational project, to verify step by step the compliance with these general principles. This is valid both because of the specific character of Profession aimed at protecting the most important single and collective good, and because every choice may result in an inappropriate use of public resources.

The difficulty in comparing, in the daily work, choices or organization polices with the respect of seemingly general principles is instead the effort that ensures the ethical behaviour and organizational choices in extremely complex systems in continuous change:

• change in demand (demographic evolution, epidemiological transition, migratory flows, ...);

• technological innovation;

• scientific progress;

• change in the availability of resources;

• important organizational innovations (interface with community resources, integrated assistance, proactive approach, patient centered medicine);

• increased citizen empowerment levels.

Today healthcare management team, integrated into the healthcare enterprise strategic administration, appears to be strongly involved in the respect of organizational ethics, precisely in relation to the roles it plays both institutionally and by delegation of the General Manager.

Traditionally the function of Health Directorate, precursor of the current health management team, originated with the Petragnani Law of 1938 (3) and oriented towards the “good governance of the Hospital”, was mostly interpreted as a “notarial” activity aimed at certifying and guaranteeing the hygienic - organizational conditions suitable for carrying out the functions of the institute.

The 1992 health reform and its amendments and additions (4) has determined the overcoming of the historical notion of Health Directorate strongly adhering to a technical - operational decision-making power of a strictly hygienic order. Today the healthcare management team stands as a link between citizens/users and the services offered embodying modern health and managerial responsibilities.

From the emanation of the 1992 health reform the path has been long and tortuous, drawing new challenges and competences of the healthcare management team in the following application areas:

• -the area of clinical governance;
• -the area of epidemiology and evaluation;
• -the area of internal operating reports;
• -the area of relations with the public;
• -the programming area;
• -the area of management control;
• -the area of Resource Management;
• -the area of quality and accreditation
• -supervision of compliance with the rules on clinical trials, by participating in the enterprise ethics committee.

These areas combine to design, as a whole, a new perspective in virtue of which health management team and the whole strategic administration have the dignity of existing, consisting in the exercise of the function of Health Product Design (5), which represents the element with the greatest ethical impacts and which implies, for the healthcare management team, an assumption of daily responsibility. The relationship between organizational ethics in health and legality passes through various regulatory provisions [the main ones date back to the years 2012 (6) and 2013 (7)] that concerned more generally the Public Administration, but also through an ever closer relationship between managerial choices, roles, management procedures and the transparency of acts and procedures. Areas must to be guarded from the perspective of the prevention of corruption phenomena and behaviour are certainly institutional accreditation, private practice, research, human resource recruiting and public contracts management. Especially in these areas, the true cultural change should pass through the conscious responsibility of the manager of public resources.

Although law, repression of crimes, prevention of incorrect behaviours through internal and external monitoring systems, transparency and citizen empowerment could help to correct and prevent specific situations, health care organizational ethics and professional ethics are able guarantee the constant implementation of correct behaviour.

Precondition for the diffusion and the rooting of the organizational ethics is the achievement of a sense of belonging to a system and its objectives. Sharing objectives and mission in a general sense by professionals could be easier in healthcare organizations compared with other systems not involved with patient’s needs. However, this is not enough to develop an ethical organization in which each practitioner feels part and protagonist of a complex patient-centered system whose purpose is to protect the most basic of rights.

Interpreting the ethical sphere of an organization and presiding over its functions and characteristics goes through the perspectives articulated by two substantial determinants:

1. development, management and continuous maintenance of clinical pathways, which transversely affect the quantity and quality of productivity of a health system incorporating the criteria of institutional accreditation recently marked in the Emilia Romagna Region by a special Resolution of the Regional Council (8) (implementation/development of a healthcare enterprise management system, guarantee of provision of services and services, adequacy and safety of structural aspects, development and maintenance of staff skills, correct communication, clinical appropriateness, improvement and innovation processes, humanization);

2. to oversee and support the values of an organization focused on clinical governance, safety, risk management and the care of the patient; starting from the daily expressions of health activities (eg hand hygiene, risk of falls, sentinel events management) (9) to the monitoring and surveillance of Information and Communications Technology (ICT) and evaluations of Health Technolgy Assessment (HTA).

In conclusion, ethics of organizational change is perhaps the most emergent issue in recent years, representing the main challenge for the management of public healthcare enterprises: not only to take charge of governing a system of highly trained professionals but also to increasingly involve them in self-identifying with the healthcare enterprise and its goals.

The health organizational discipline has made a great progress in recent years becoming able to perform the role of vigilance towards unethical behaviours creating appropriate organizational contexts and, at the same time, governing a process of identity matching between the individual Professional and the healthcare enterprise.

Therefore it is the authors’ opinion that any daily professional choice of health management professionals, such as those involved in health management teams, should overcome individual and personal ethics to reach the level of organizational ethics and shared decision making by individual Professionals.