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Milton Friedman has long maintained that the "sole aim of corporations is to maximize the profits for its stockholders. Yet, the events through the last third of the 20th century demanded that powerful corporations "be attentive" to the consequences their means to profit making was having on the environment, employment levels, and fair wages, among other things. As this latter view became more pronounced, it was referred to as the stakeholder theory,1 which challenges the Friedman theory as too narrow.
1
Specific expectations and requirements for those doing the work of the organization
Business terms
customer service/customer satisfaction
Ethical terms
Integrity, honesty, and compassion
Guidance from Personal/Professional Values A set of principles and values that describe standards of conduct Professionally focused
Patient well-being and privacy
Guidance from Guidance from Guidance from Guidance from Law and Regulation Policy and Procedure Organizational Principles Personal/Professional Values And Values Guidance from Society and Community
S = Self
What guidance do my personal values provide in this case?
S = Society
How do community/society values and expectations apply to this situation?
Chinese Saying:
He whose virtues exceed his talents is a superior man; he whose talent exceeds his virtues is a dangerous man.
Source: Porter-OGrady & Wilson
Value Statements
We recognize and affirm the unique and intrinsic worth of each individual. We treat all those we serve with compassion and kindness. We act with absolute honesty, integrity and fairness in the way we conduct our business and the way we live our lives. We trust our colleagues as valuable members of our healthcare team and pledge to treat one another with loyalty, respect and dignity.
Therefore I say: One who knows the enemy and knows himself will not be in danger in a hundred battles. One who does not know the enemy but knows himself will sometimes win, sometimes lose. One who does not know the enemy and does not know himself will be in danger in every battle. Sun Tzu
Ethical dilemma
The support of your board chairman is crucial for a new project that is not popular with your hospital's doctors. You want to spend $10 million on a needed renovation in the intensive care unit, while a good number of the doctors want that money spent on new equipment. The board chairman, who has a lot of influence with the doctors, has told you that his friends son would like to do the bond work for the renovation.You fear he wont get behind the renovation if the hospital doesn't use the firm he wants.
-TERESE HUDSON THRALL
KEITH PRYOR Governance consultant and former system CEO, Bryn Mawr, Pa.
There are often more valid requests for resources than there is funding. I may improve my position by following a disciplined process for spending money that incorporates physician input. I'm not looking to build doctor support, but to use a process that produces an objective answer. Maybe the ICU renovation isnt the best thing to do. If that process shows that the renovation should go forward, I'd follow a similar process for selection of legal counsel. Companies should disclose relationships to those in leadership positions at the hospital. If the friends son is recommended via this process, any conflict should be disclosed to the board. In the meantime, I'd give my board reports outlining conflict-of-interest questions posed by the attorney general of Pennsylvania to the leadership of the Allegheny Health System Board.
WILLIAM GONZALEZ Health care adviser and former system CEO, Chicago
I would erode my relationship with the doctors if they discover that the chairs favored firm did the bond work for a project they don't support. It would look as though I were trying to improve my position with the chair at their expense. Instead, I would reopen the discussion of the ICU renovation, involving physicians and the board's construction committee. Even if I'm not able to get doctor support, I've made an attempt to justify it. I'd also talk with the chair about conflict of interest. He should inform the board about his ties to the law firm, which should be considered along with others based on best terms and interest costs. The chair shouldn't participate in voting or discussion. A trustee should never use his or her position to influence the choice of a vendor, even if that vendor does quality work.
False Claims
Govt purchasing services vs. goods Services provided to beneficiaries of programs rather than govt agents Services provides at thousands of remote sites Complexity of prof services make it difficult to question quality and appropriateness Personal and confidential nature prevents direct observation by the govt at time of service.
Problem!!!
Govt must rely on the word of the provider or written documentation.
Types of fraud
Claims for services never rendered Upcoding
Some providers see nothing wrong with false statements to justify service to patients need service and cannot afford it.
Federal offense
False claims for Medicare/Medicaid is a felony New federal offenses apply to private as well as public programs.
Examples of Fraud
(False Claims) One physician billed $350,000 over a 2 year period for comprehensive physical exams of residents without ever seeing a single resident. Falsified medical records to indicate nonexistent services were rendered.
(False Claims)
A psychotherapist working in nursing facilities manipulated billings codes to charge for 3 hours of therapy when he spent only a few minutes with each resident. 3 hours of psychotherapy is highly unusual and often clinically inappropriate.
(False Claims)
Speech therapist overstated time spend on each session claimed Claim showed 20 hours with residents every day. Some residents never met the specialist and some were dead at the time the specialist claimed to have provided service to them.
(False Claims)
Mobile x-ray unit billed for two x-rays when only one was taken. Company personnel were not certified to take x-rays.
Optometrist: 25 consultation in one day. Audiologist: Orders for hearing exams not medically necessary.
U.S. v. Mackby
Mackby was managing director of a clinic. He was obligated to be familiar with legal requirements for Medicare reimbursement for PT services. Ignorance of the law was no excuse. 20% percent of clinic patients were Medicare Acted with reckless regard or in deliberate ignorance with knowledge of false claims. Penalty: $5,000 - $10,000 per claim, plus 3 times damage incurred by government.
Kickbacks
(Medicare Anti-kickback Act) It is unlawful to knowingly and willingly give or receive anything of value to induce someone to refer a Medicare/Medicaid patient Or induce someone to purchase something from which payment may be made under these programs. Felony: <$25,000 fine, 5 years imprisonment, exclusion from government payment programs..
Self-referral
Physicians refer patients to facilities that they own in whole or on part.
Deontological Theories
A duty-based theory
Utilitarianism
Three questions are left unanswered:
Who is to be included in the moral reference group? What is to count as good or bad? What sort of alternative is to be considered?
Theories of Value
Subjective Preference
Maximize satisfaction of preferences and minimize frustration.
Hedonism
Pleasure is good, pain is bad.
Pluralism
Four fundamental intrinsic goods
Pleasure Knowledge Virtue Justice
Nonmaleficence
Do no harm
Beneficence
Doing good
Justice
Strive for equality in welfare and opportunity
Common Rationalizations
Its not really illegal or immoral. Its in my (or the organizations) best interest. No one will find out. Since it helps the organization, the organization will condone it and protect me.
Ethical questions
The Does it provide DoesThe it respect The Is it fair the Utilitarian greatest good the rights of the Rights Justice View and View equitable? for the greatest individual View number? affected? Times are changing. Individual rights and social justice are challenges which will require supervisors to base ethical standards on nonutilitarian criteria.
A guide for ethical behavior. Questions to ask yourself. 1. How did this problem occur in the first place?
2. Would you define the problem differently if you stood on the other side of the fence? 3. To whom and to what do you give your loyalty as a person and as a member of your organization/ 4. What is your intention in making this decision? 5. What is the potential for your intentions to be misunderstood by others in the organization? 6. How does your intention compare with the probable result? 7. Whom could your decision injure? 8. Can you discuss the problem with affected parties before you make the decision? 9. Are you confident that your position will be as valid over a long period of time as it seems now. 10. Could you disclose your decision to your boss or your immediate family? 11. How would you feel if your decision was described, in detail, on the front page of your local newspaper?
Group Decision-making
Advantages more information more alternatives solution acceptance legitimacy Disadvantages time consuming minority domination conformity ambiguous responsibility
Ethics
Ethics
Morality Conscience Legality Trust Values Responsibility Integrity
Front-Page Test
How would you like to see this behavior written up on the front page of your hometown newspaper?
Mirror Test
How will you feel about this behavior when you look in the mirror?
Approaches to Ethics
Full Potential Approach Black & White Approach Best-Ratio Approach
Figure 4 - 4: Guidelines for Handling Ethical Dilemmas Before taking any action in situations involving ethical dilemmas, answer the following questions: What solution is most likely to build trust among those involved? What solution fits best into the companys value system? What solution will pass the morning-after, frontpage, mirror, role reversal, and common sense tests? What solution is most likely to enhance the organizations integrity? What solution is the most responsible option?
Theres a tendency today to absolve individuals of moral responsibility and treat them as victims of social circumstance. You buy that and you pay with your soul. What limits people is a lack of character. Tom Robbins
Character
What sort person should you strive to become? What are your core virtues?