The instruction for this assignment is in the attached files. Tutor is writting an 8-page document. that I need in 2days. REFLECTIONS ON HEALTHCARE LEADERSHIP ETHICS Redefining ethical leadership in a 21st-century healthcare system Anita Ho, PhD1,2,3 and Stephen Pinney, MD, MEd, FRCS(C)4 Healthcare Management Forum 2016, Vol. 29(1) 39-42 ª 2015 The Canadian College of Health Leaders. All rights reserved. Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0840470415613910 hmf.sagepub.com Abstract Traditional ethical leadership in healthcare concentrated on the oversight of the individual provider–patient relationship. However, as care delivery becomes predominantly team-based and integrated across provider organizations, these ethical frameworks also need to consider meso- and macro-factors within the system. These broader issues require managers and administrative leaders to augment their ethical perspectives beyond current and prospective patients with those of the team, organization, and broader system, where high levels of coordination and oversight are essential. Administrators are increasingly ethically accountable not only for how individual care encounters are conducted (micro level) but also for how the system is organized to deliver and ensure quality care for patients receiving care (meso level) and service populations who turn to them for care when needed (macro level). Introduction The nature of healthcare delivery is transforming, which in turn demands that definitions of and frameworks for ethical leadership change accordingly. Traditional ethical leadership has concentrated on the practices and behaviours of the professional, particularly within the micro-level provider-patient relationship. However, 21st-century healthcare delivery is becoming predominantly team-based and integrated, and health systems are increasingly embracing concepts of population health (eg, system-wide chronic disease management programs). These fundamental changes demand that modern healthcare systems also consider the meso- and macro-factors shaping the impact of leadership ethics. ”Meso” factors pertain to how a healthcare team, unit, or institution is organized, and ”macro” factors embrace system and population-based considerations that affect how care is coordinated and delivered. These multi-level issues require administrative leaders to expand their ethical mandate to include broader imperatives of performance and accountability. As high levels of coordination and oversight are necessary to achieve objective outcomes and metrics, ethical healthcare delivery requires managers, executives, and even trustees and policy-makers to be held accountable not only for how individual care encounters are conducted but also for how the system is organized to ensure quality care within and across defined populations. The evolving system and the accompanying problems Traditional ethical leadership in healthcare has focused on oversight of individual clinicians’ performance and outcomes for identifiable patients. The dyadic therapeutic encounter between an individual patient and his or her physician was the locus of ethical responsibility and accountability, which would begin on first contact—a patient’s initial clinic visit or after admission to the hospital. Clinicians had to respect individual patients’ values and preferences (autonomy and consent), avoid harm to patients (non-maleficence and preventable morbidity), enhance the well-being of those under one’s care (beneficence, advocacy, and standards of care), and treat all patients fairly without discrimination (social justice and patient-centred care). In this traditional model, healthcare leaders had an ethical responsibility to ensure that each healthcare provider in their clinic or hospital fulfilled such duties towards patients in their care. Ethical considerations related to the performance of individual practitioners in specific clinical encounters continue to be relevant—after all, even isolated cases of disrespect for patient or misdiagnosis can compromise patient outcomes and the public’s trust in the profession and the healthcare system. However, in recent decades, medical technologies and healthcare delivery have become increasingly high-tech, complex, and interprofessional. Instead of receiving care from individual, isolated, and autonomous physicians, patients are increasingly treated by healthcare teams and programs across various disciplines, specialties, professions, organizations, regional health authorities, or systems of providers. While these changes have produced longer life expectancy and better quality of life, they have also revealed problems in how healthcare is delivered. In its landmark publication, Crossing the Quality Chasm, the Institute of Medicine (IOM) reported consistent care delivery problems in two intersecting areas.1 First, unacceptably high numbers of preventable medical errors persist. In team-based settings, quality failures are no longer purely the results of poor or incompetent 1 2 3 4 Centre for Applied Ethics, University of British Columbia, Vancouver, British Columbia, Canada. Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. Providence Healthcare, Vancouver, British Columbia, Canada. St. Mary’s Medical Center, San Francisco, CA, USA. Corresponding author: Anita Ho, Vancouver, British Columbia, Canada. E-mail: [email protected] 40 individual performance that require isolated remedies. Rather, they are increasingly institutional or system problems— predictable and avoidable problems that occur because of how the delivery system is organized. As noted in the IOM’s other report, To Err is Human, ”The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.”2(p5) Second, wide-scale variations in medical practice, sometimes up to 200% to 300%,3 have raised questions about the effectiveness, efficiency, and quality of healthcare services, prompting calls for decreasing variation in a complex system. As preventable medical errors and excessive variation at the population level can harm large numbers of patients, they demand an organizational and system approach to ethical leadership. Whether it is closely monitoring performance and outcome measures, providing timely feedback to practitioners, or establishing processes to implement improvement strategies, healthcare executives must be willing and able to fulfill their ethical obligation to work with various levels of policy-makers, administrators, clinicians, and staff to enact necessary changes to address these problems. Ethical leadership for the new paradigm The following micro-, meso-, and macro-level concerns in healthcare delivery illustrate the aforementioned evolving needs of ethical leadership to address not only individual but also institutional and system issues. Consider the following micro-level scenario. Dr. Jones was a busy joint replacement surgeon at Hospital A. An independent physician, Dr. Jones was well liked by his patients who found him pleasant and keen to book surgeries quickly. However, anecdotal evidence suggested that Dr. Jones had a higher than average post-operative infection rate. Those who worked with him observed that he operated quickly and sometimes cut corners. The infection rate in the hospital had not previously been accurately measured, and given the traditional model of physician autonomy, Dr. Jones was allowed to practice in an unrestricted manner for many years. However, the introduction of prospective outcome metric measuring in the form of a joint registry showed that Dr. Jones’ post-operative infection rate was four times that of the other joint replacement surgeons at Hospital A. This represents a ”micro”-level ethical leadership issue—administrators can rightly assign the detected deficit to Dr. Jones. Traditionally, this has been the level at which healthcare leaders have exercised their ethical duties—that of monitoring individual providers. The ethical duty of non-maleficence would require leaders at Hospital A to act on the information and ensure that Dr. Jones’ discrepancy is addressed, such as by performing a practice review and taking remedial actions accordingly. Now consider a meso-level scenario. Imagine two neighbouring hospitals, each with five orthopaedic surgeons who regularly perform joint replacement surgery. The post-operative infection rate among surgeons within each hospital is very similar. However, joint registry data show that the average post-operative infection rate at Hospital B is one-quarter of that of Hospital A’s. All Healthcare Management Forum surgeons at both hospitals have similar clinical training and experience. The surgeons at Hospital A are assigned different nursing staff each time they operate and as a result spend considerable time orienting and reorienting staff members regarding protocols and procedures. There is variation among surgeons’ practices and nurses’ adherence to sterile technique and no coordinated approach to staffing. The operations leader is housed in the corporate office, with access to electronic data but little connection to the frontline operations to monitor first-hand whether the organization’s safety protocols are being followed, or how multiple sources of potential quality gaps may be affecting patient outcomes. With many staff members floating between units operating as independent practitioners, there is no systematic approach to assess the clinical pathways in patients’ episodes of care or address practice variation, making sustainable quality improvement interventions difficult. This is contrasted with Hospital B, which proactively developed a designated joint replacement surgical team led by a frontline clinician and allocated evidence- and outcome-based incentive payments. The surgeons are incentivized to work collectively, and nurses and other team members have a deep understanding of the surgical procedures and an excellent knowledge of the protocols. When a deficiency is identified, it is immediately addressed by the surgical team leader, who would debrief not only the individual clinician who may potentially be violating safety measures but also the whole team regarding how to prevent and respond to such quality gaps as a unit. This coordinated team-based approach to care delivery has substantially improved Hospital B’s operating room efficiency, decreasing the length of each joint replacement surgery and the resulting complication rate for patients. This meso-level problem in Hospital A resulted from how the institutional care delivery system is organized. Most quality failures in modern medicine happen because complex care processes involving multiple care providers of various disciplines occur within a healthcare environment that is poorly designed or uncoordinated.4 The administrative leaders at Hospital B took a proactive approach to organizing care delivery at their institution—including creating and monitoring a highly coordinated multidisciplinary joint replacement team as well as ensuring timely feedback on potential quality failure for all team members. In contrast, the administrative leader at Hospital A, while well intentioned, had little understanding of the practical realities or oversight of how surgical care flows. Micro-level lapses (eg, violation of sterile technique) intersected with organizational inadequacies (eg, lack of provider coordination), resulting in meso-level failures. In complex modern healthcare, professional and organizational ethics both require that we take leadership accountability seriously.5 As poor care organization predictably leads to complications, hospital readmissions, declines in functional status, and economic consequences,6 leaders such as those at Hospital A are ethically accountable for their success or failure in learning from best practices (eg, Hospital B) and enacting necessary improvements. Like individual practitioners, health leaders of various roles in a multi-layered system can no longer work in Ho and Pinney isolation. A failure to appropriately coordinate with relevant stakeholders to organize a complex system for optimal care delivery, even if inadvertent, represents a meso-level ethical breach of non-maleficence on the part of the administrative team. The necessity of good coordination among all levels of care delivery signals that 21st-century health systems must proactively manage the healthcare needs of large populations over multiple sites of care. This macro-level leadership demands that care be integrated across networks and that robust care delivery outcome goals are met for the entire patient population. Government-level administrators (eg, Ministry of Health, health authorities) and senior executives (eg, Chief Executive Officers [CEOs] and Chief of Staff) are ethically required to work with their counterparts and various levels of clinicians and support staff to determine oversight structure, performance accountability, resource allocation criteria, and appropriate fiscal management that will ensure safe, effective, and timely care across the whole system for present and future patients. Imagine a health region with a population of 800,000 residents, led by a CEO and an executive team, and overseen by a board of directors. The health system epidemiologists had calculated that 5,000 people would require assessment each year by a hip specialist, and 1,000 of these patients would need a hip replacement. That number will predictably rise in coming years given the aging population. Suppose the system has been performing 800 hip replacements each year. From a population-health perspective, at least 200 people each year will be denied timely care and thus will have to suffer prolonged pain and reduced functioning. These 200 people may not be identifiable individuals and are not technically ”patients” until they have been assessed by a healthcare provider—it is only then that a therapeutic relationship will be formed. This is where ethical obligations and leadership take us to a new dimension. From determining how to distribute public funding and prioritize various health conditions to eliminating waste and inefficiencies in the healthcare system, populationbased healthcare or macro-level management demands are ethical demands for high-level executives. They require those leading the healthcare system to take responsibility and accountability for the care that needs to be provided to all current and prospective patients within the system. It requires health system leaders to assess the population needs and proactively work with and incentivize relevant parties—from government officials to bedside clinicians—to create and organize sustainable programs to ensure that these predictable healthcare needs will be met efficiently and effectively. While volumes have been poured over the rising healthcare costs and capped funding, it is noteworthy that efficiency in various health regions in Canada is estimated to be between 0.65 and 0.82,7 suggesting substantial waste and significant potential for improved capacity. This ethical responsibility to ensure efficient and effective disease management programs are in place goes beyond being respectful to patients who come through the clinics and hospital. It requires careful consideration of the intersection between leaders’ ethical duties of 41 beneficence, non-maleficence, and justice. To promote the well-being and prevent unnecessary suffering of the population, CEOs and their executive teams must also consider their ethical obligation of promoting distributive justice. They need to distribute technological and human resources fairly, efficiently, and effectively so that quality care can be delivered to the population. Ethical leadership in the macro context requires high-level administrators within the system to coordinate various aspects of healthcare, from community care to acute care to palliative and hospice care. Failure to undertake steps to anticipate and address population-based healthcare needs represents an ethical breach at the macro level on the part of high-level administrators. Conclusion This article has argued that ethical leadership in healthcare needs to be redefined to accommodate the changing nature of healthcare delivery. Most health professions include codes of conduct and define ethical standards for individual patient care encounters. Managers and executives are also bound by professional ethics. However, few professions embrace a broader system responsibility and accountability beyond providers’ individual performance or their own institution’s value systems. As care becomes increasingly integrated and population based, a broader systematic approach to ethical healthcare leadership is required. At the urging of groups such as the IOM, fundamental reform of the healthcare delivery is occurring, and healthcare leaders have a much more pronounced role in ensuring that current and future patients receive appropriate care. High-quality modern healthcare delivery is expectably integrated, team-based, and outcome oriented, requiring proactive system redesign (meso level). Additionally, large health systems must focus on ensuring appropriate care delivery for the populations they serve (macro level). Administrators, not simply individual healthcare providers, are thus responsible for the quality of care that patients receive in this new model of care. The coach and general manager are ultimately held responsible for the performance of a professional hockey team—and the president and board of directors are held responsible for the success of a professional hockey league. Similarly, healthcare administrators should be held accountable for the quality of healthcare that is delivered and the overall performance of the health system they are running. References 1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001. 2. Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 2000. 3. Mitchell JJ. The findings of the Dartmouth Atlas Project: a challenge to clinical and ethical excellence in end-of-life care. J Clin Ethics. 2011;22(3):267-276. 42 4. Reason J. Human error: models and management. BMJ. 2000;320: 768-770. 5. Pellegrino E. Prevention of Medical Error: Where Professional and Organizational Ethics Meet. In Virginia A. Sharpe, ed. Accountability: Patient Safety and Policy Reform. Washington, DC: Georgetown University Press; 2004:83-98. Healthcare Management Forum 6. Berwick DM, Hackbarth AD. Eliminating waste in US healthcare. JAMA. 2012;307(14):1513-1516. doi:10.1001/jama. 2012.362. 7. Canadian Institute for Health Information. Measuring the level and determinants of health system efficiency in Canada. Ottawa, Canada: Canadian Institute for Health Information; 2014. • Assignment Topic: Health disparities/social determinants of health: —-This whole assignment is about demonstrating effective leadership. Focal Point: Focus on vulnerable or high-risk groups and on decreasing disparities between groups. You can select a specific group with a focus on experience of care, services, and resources (quality and satisfaction); improving the health of the population; and reducing per capita cost. This will be the focus for the coalition. The topic must fit in with the scenario below: And the scenario should fit Dunn, North Carolina. Choose focus persons from the city of Dunn. Scenario Government officials are taking action to address a chronic population health concern in your area. As a member of this community, you have a good understanding of the local demographics and population health issues, including the potential implications for policy making, health care systems, service utilization, clinical practice, education, and the workforce. In your role as a doctoral graduate and health care practitioner, you have been asked to: • Evaluate key aspects (including the social determinants of health) of the selected population health issue from the topic list. • Lead an interprofessional team of your choosing (a coalition of community members and organizations, clinical providers, health care organizations, and civic and governmental agencies) to achieve the coalition’s goal(s), which may include prevention efforts, quality improvement, service utilization, and the reduction of health care costs. This position requires the ability to lead an interprofessional coalition, identifying potential barriers and best practices for communication and collaboration and addressing issues relevant to diversity and inclusion, ethical practice, and the use of evidence in the field to promote change. To complete this assignment, you need to: • • Analyze the impact of factors that contribute to this chronic population health concern. • Examine the situation from a population health perspective. • Provide context surrounding this concern. • Identify the affected groups, and the environmental, social, and financial factors. Form a collaborative, interprofessional coalition to address this chronic population health concern. • Consider, among others, key community members and organizations, clinical providers, and local and state agencies when making your selections. • Select 5–10 members. ? Who must be included? ? Why? o How will member selection contribute to the goal? o What potential issues might arise affecting interprofessional collaboration? o What strategies are needed to optimize collaboration and communication among coalition members? • • • Explain potential ethical issues that might be relevant for the coalition to consider in addressing its mission. o Consider access to care, financial barriers, environmental constraints, and the distribution of resources. o Explain how ethical principles would apply in particular situations on a micro or meso level. ? Micro level: individual care encounters. ? Meso level: how systems are organized to deliver and ensure quality care for patients and populations (Ho & Pinney, 2016). o Consider ethical codes of conduct applicable across disciplines represented in your coalition. o What evidence supports your conclusions? Explain the principles of diversity and inclusion applicable to the formation of your coalition and its interactions with the community. o Consider the impact of a diverse team on achieving coalition goals. o How would you work within the coalition to establish a culture of inclusion, respect, and value? o How would you promote community engagement, cultural awareness, health equity, and access to resources? Resources can include, but are not limited to, medications, transportation, and environmental resources. o What are some best practices for interprofessional communication for this group? o What evidence supports your conclusions? Explain how literature and research in the field can be used to develop best practices for addressing this chronic population health concern. o Locate two current, peer-reviewed studies that coalition members should consider as foundational to developing an evidence-based intervention for the situation. o Briefly explain how each study is relevant to the chronic population health concern. Requirements: • • • • • APA style 7th edition Headers, title page, an outline. Use the bullet points outlined above to get the contextual aspect of the paper and form a table of content. The paper should have 8 pages, not including the title page, table of contents, and reference list. At least four credible sources-peer reviewed in the limit between 1-5yrs. Sources should not be taken beyond 5yrs. Pay attention to the rubric to control the content of the paper. Reference Ho, A., & Pinney, S. (2016). Redefining ethical leadership in a 21st-century healthcare system. 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