Jack Lynch, FACHE President & CEO Main Line Health …hlndv.ache.org/wp-content/uploads/sites/19/2016/01/... · · 2017-04-09Jack Lynch, FACHE President & CEO Main Line Health ...

Jack Lynch, FACHE

President & CEO

Main Line Health

May 28, 2014

Professionalism and Ethics *

This area focuses on the development, monitoring and maintenance

of procedures to ensure the needs of professional staff are met.

Ethics includes identifying, monitoring and disseminating codes of

professional conduct; understanding the implications of ethical

decisions; providing procedures to monitor standards to behavior

within the organization; and determining, maintaining and monitoring

accountability procedures.

* ACHE Reference Manual

2

16 (or 8%) of the 230 questions are on the topic of Professionalism and

Ethics

Eight Knowledge Areas Under Professionalism and Ethics:

1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic

Oath, AMA)

2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)

3) Ethics Committee’s Roles, Structure and Functions

4) Cultural and Spiritual Diversity

5) Conflict of Interest Situations

6) Professional Norms and Behaviors

7) Consequences of Unethical Actions

8) Ethical Implications of Human-Subject Research

3

Familiarize Yourself With The Following (all on www.ache.org):

• ACHE By-Laws

• ACHE Code of Ethics

• ACHE Ethical Policy Statements (9)

• ACHE Professional Policy Statements (10)

• ACHE Public Policy Statements (6)

• ACHE Ethics Self-Assessment

4

1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic

Oath, AMA)








5

Purpose is to bring together persons with like

professional interests for educational, social and

shared goals.

Members have an obligation to their profession to

mentor and educate, maintain standards and encourage

those who are interested in joining.

6

From its founding in 1933, when it was known as the

American College of Hospital Administrators, to the present,

the American College of Healthcare Executives (ACHE) has

been a leader in establishing the profession of healthcare

management.

Generic hallmarks of professions include a public service

orientation, self-regulation, a Code of Ethics and expectations

such as assuring competence of members through continuing

professional education.

7

8

Preamble:

Standard of conduct for

executives in their professional

relationships and individual

behaviors

Merit the trust, confidence and

respect of colleagues and the

public

Protect the rights, dignity and

interests of all seeking healthcare

Support an equitable, accessible,

effective and efficient healthcare

system

You have responsibilities to: Your Profession

Your Patients

Your Organization

Your Employees

Your Community

Report

Hippocratic Oath

+

American Medical Society

+

American Nurses Association

+

American Osteopathic Association

+

American Academy of Physician Assistants

9

When a healthcare organization’s goals conflict with the

stated position of a professional society, the professional

individual’s responsibility is to:

1) Make known the stance of the profession and

reconcile the divergent positions.

2) Enlist the support of professional colleagues to alter

the organization’s position.

3) Support the professional society’s position.

4) Support the organization’s position.

10

When a healthcare organization’s goals conflict with the

stated position of a professional society, the professional

individual’s responsibility is to:

1) Make known the stance of the profession and

reconcile the divergent positions.

2) Enlist the support of professional colleagues to alter

the organization’s position.

3) Support the professional society’s position.

4) Support the organization’s position.

11

When considering ethical principles useful to healthcare

executives, which of the following is incorrect?

1) Respect for persons, including Autonomy, Truth

Telling, Confidentiality, Fidelity.

2) Beneficence - an obligation to act in charity and

kindness.

3) Non-maleficence - first do no harm.

4) Justice - maintain different levels of care and services

based on social status and the ability to pay.

12

When considering ethical principles useful to healthcare

executives, which of the following is incorrect?

1) Respect for persons, including Autonomy, Truth

Telling, Confidentiality, Fidelity.

2) Beneficence - an obligation to act in charity and

kindness.

3) Non-maleficence - first do no harm.

4) Justice - maintain different levels of care and

services based on social status and the ability to

pay.

13

1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic Oath,

AMA)








14

15

Utilitarianism Measuring the end result

produced by a certain action

Deontology A moral philosophy based on

duty (there are right & wrong

actions, regardless of the result)

Respect

Autonomy

Confidentiality

Fidelity

Truth

Beneficence

Non-maleficence

Justice

Complete and Truthful

Information

Participation in

Healthcare Decisions

16

Respect

Non-discrimination

Confidentiality

Privacy

Ethics is the driving force…

Law is the answer (“how to”)…

And the law is HIPAA

17

The "HIPAA Preliminaries" must be in place:

Privacy Officer

Policies and Procedures

Notice of Privacy Practices POSTED

Releasing only what is "Minimally Necessary“

Business Associate Agreements if:

a) NOT an employee

b) NOT already covered by HIPAA

c) CANNOT do their job without access to PHI

18

19

You may release PHI to

another provider for:

Treatment

Payment

Operations

Other disclosures require

patient authorization

“Covered entities are free to

engage in communications as

required for quick, effective and

high-quality healthcare.”

HHS Guidance on HIPAA

FAQs on Incidental Uses & Disclosures

Question No. 6

20

“Tiers” of penalties based on type

of violation:

“Reasonable”

“Knowing”

Constituting “willful neglect”

Which tier is enforced is

discretionary based on the

nature and extent of the

violation and the extent of

any harm done.

$100 per violation not to exceed $25,000 per calendar year

$1,000 per violation not to exceed $100,000 per calendar year

$10,000 per violation not to exceed $250,000 per calendar year

$50,000 per violation not to exceed $1,500,000 per calendar year

21

American Recovery and Reinvestment Act of 2009 - expands

protection of protected health information (PHI), especially patient

information that is in digital format and transferred electronically

Definition of a “Breach”:

1) The unauthorized acquisition, access use, or

disclosure of PHI.

2) Acquisition, access use, or disclosure of PHI in

good faith within the scope of employment is

not a breach.

3) An "inadvertent disclosure" within a provider's

office is not a breach.

22

If you have a breach, you must notify the affected

patient within 60 days of discovery.

You must notify the Secretary of Health and Human

Services and media outlets if your breach affects

more than 500 patients.

Vendors also must notify patients.

Attorneys general in every state are now empowered

to enforce HIPAA violations.

23

The Department of Health and Human Services has been

answering "Frequently Asked Questions“ (FAQs) since

early in the Privacy Rule creation process, and they have

been posting the questions and answers on the web.

This is the most definitive information you can obtain

about HIPAA. It’s free, easily accessible and extremely

accurate (http://www.hhs.gov/ocr/hipaa)

TRUE OR FALSE: All of the following are commonly

recognized to be a right of each patient:

1) Receive considerate and respectful care.

2) Access protective services.

3) Communicate with a caregiver in the language of

the patient’s choosing.

4) Be informed about and participate in decisions

regarding their care.

24

TRUE OR FALSE: All of the following are commonly

recognized to be a right of each patient:

1) Receive considerate and respectful care.

2) Access protective services.

3) Communicate with a caregiver in the language of

the patient’s choosing.

4) Be informed about and participate in decisions

regarding their care.

25

With respect to the processes by which healthcare organizations maintain the

confidentiality, security and integrity of the medical record, all of the following

statements are true except:

1) The original medical record of a patient being transferred from one healthcare

organization to another may accompany the patient to the new organization.

2) Healthcare organizations must have a mechanism to preserve the

confidentiality of data / information identified as sensitive.

3) The organization must have a mechanism to safeguard records against loss,

destruction, tampering and unauthorized access or use.

4) Written policies must require that medical records may be removed from the

organization’s jurisdiction only in accordance with a court order, subpoena or

statute.

26

With respect to the processes by which healthcare organizations maintain the

confidentiality, security and integrity of the medical record, all of the following

statements are true except:

1) The original medical record of a patient being transferred from one

healthcare organization to another may accompany the patient to the

new organization.

2) Healthcare organizations must have a mechanism to preserve the

confidentiality of data / information identified as sensitive.

3) The organization must have a mechanism to safeguard records against

loss, destruction, tampering and unauthorized access or use.

4) Written policies must require that medical records may be removed from the

organization’s jurisdiction only in accordance with a court order, subpoena or

statute.

27


AMA)








28

Institutional Ethics Committees

Interdisciplinary (should include physicians, nurses,

administration, clergy, patient representatives)

Committee may extend advice, consultation, education &

analysis

Ethics Committees are historically focused on Biomedical

issues [Quinlan, 1976)

Over time have also been used to resolve administrative

ethical issues; may be required under your State Law

29

30

Individuals

Physician-Assisted Suicide

Treatment Refusal by Surrogate or Legal

Representative (Terry Schiavo)

Refusing Treatment Absent Terminal

Illness (Nancy Cruzan)

Moral Status of Gametes and Embryos -

storage and surrogacy

New Reproductive Technologies: IVF,

embryo transplants, egg and sperm

donors, surrogate mothers

Abortion / Human Cloning / Organ

Donation

The Elderly and Access to Long-Term

Care

Autonomy of Persons in Nursing Homes

Hydration and Nutrition

Organizations

Promotion of common good

Role of the community in the

healthcare system

Preservation of human resources

Definition of health

Role of law and government

regulation

Promoting access

Conflicts of interest

Allocation of resources in era of

cost containment

Technology

31

Institutional Review Board

Required if your institution is involved

in research that may pose harm to

human subjects

HHS, State Law & various state &

federal agencies

Prospectively review research that

involves human subjects

Issues of consent, risk, value of

research

Infant Care

Federal Child Abuse

Amendments of 1984

Involved when a child has a life-

threatening condition

Review of any case involving

the withholding of care

Should be involved in the

education of families and staff

on issues involving the

possibility of withholding of care

Person states their wishes about accepting or refusing

medical and surgical treatment.

Types of advance directives:

1) living wills

2) natural death acts and death with dignity laws

3) do not resuscitate

4) substituted judgment

Patient Self-Determination Act (PSDA) requires health

services organizations that participate in Medicare or

Medicaid to inform people they serve about advance

directives.

32

Benefits to healthcare organizations:

1) They recognize / maximize patient autonomy and

develop a covenantal relationship with patients

2) Give caregivers decisions and decrease uncertainty

as to patient wishes

3) Decrease patient and surrogate / family dissatisfaction

with the organization

4) Decrease need for legal intervention

5) Make more efficient use of organizational resources

33

Which of the following is not an Advanced Medical

Directive?

1) Living wills

2) Euthanasia

3) Surrogate decision making

4) Do not resuscitate

34

Which of the following is not an Advanced Medical

Directive?

1) Living wills

2) Euthanasia

3) Surrogate decision making

4) Do not resuscitate

35

The purpose of the ACHE Ethics Committee is to

review and recommend action on ethical violations to

which group?

1) Executive Committee

2) Board of Governors

3) Council of Regents

4) Membership Committee

36

The purpose of the ACHE Ethics Committee is to

review and recommend action on ethical violations to

which group?

1) Executive Committee

2) Board of Governors

3) Council of Regents

4) Membership Committee

37


AMA)








38

This definition and focus incorporates the strengths that

divergent backgrounds bring to any interaction.

It shifts the philosophy from one of ethnocentrism

(“normal is what I define and expect”) to one of ethno-

relativism (“normal” is a context-based term; what is

“normal” for you is something I need to learn).

39

Cultural and Spiritual Diversity Impact:

-- health literacy

-- definition of a family

-- patient interactions, including personal space,

gestures, eye contact, body language, and

preferences for whether / how bad news should be

shared

-- language use; sense and respect for time

-- patient role with the physician (goal is to move away

from paternalistic to collaborative relationship)

-- cultural context of illness and disease

-- the use of traditional and alternative health care

40


AMA)








41

Worthley has provided five hallmarks of conflict of interest to assist

healthcare executives in determining whether a conflict is present:

1) Competing obligations: obligation to organization vs.

obligation to friend

2) Appearance standard: the “appearance of impropriety” may

compromise the interests of the organization. Would a

reasonable person be suspicious of misconduct?

3) Myopia: people close to the situation do not see it as

clearly as others

4) Fairness: actions taken within a conflict-of-interest situation

can be unfair to the legitimate stakeholder

5) Confusion: between official and unofficial power; informal,

unofficial, interactions support confusion

42

ACHE Code of Ethics states: “Avoid the improper

exploitation of professional relationships for personal gain”

and “Disclose financial and other conflicts of interest”.

ACHE members should ensure that they personally

disclose any potential conflict of interest situations, and

have an expectation and system in place for board

members, medical staff members, management team and

clinicians to make full disclosure of any possible conflicts

of interest before pursuing or entering into relationships

with potential business partners.

43

44

The scandals of Enron, WorldCom

and Tyco led to greater demands for

self-disclosure, transparency and

internal controls

Sarbanes-Oxley Act of 2002

imposes guidelines to improve

the accuracy and reliability of

corporate disclosures

45

Encourage employees to report

unethical behavior (with protection)

Code of ethics and standards of

conduct for executive officers &

board members

Continuously search for conflicts of

interest in the organization

Certification of financial reports

by CEOs and CFOs

Ban on personal loans

Public reporting of CEO and

CFO compensation and profits

Internal independent audit, with

external audit certification

G. Pozgar

“Legal Aspects of Health Care

Administration”

Consciously seek to avoid situations before they

occur (i.e., prevention)

Once a conflict has developed, the individual must

disclose the conflict and remove themselves from a

position of decision making

Institute a “no-gratuities / no-gift” policy so it leaves

nothing to chance (gifts of all kinds, meals and

entertainment)

46

According to ACHE’s Code of Ethics, one way that

healthcare executives can avoid or minimize the

negative implications of conflict of interest is to:

1) Develop a public relations plan to address potential

conflict-of-interest scenarios.

2) Not participate in the specific decision where conflict

may exist.

3) Ensure members submit annual lists of major activities

and holdings for inspections.

4) Make the conflict known to those in superior positions.

47

According to ACHE’s Code of Ethics, one way that healthcare executives can avoid or minimize the negative implications of conflict of interest is to:

1) Develop a public relations plan to address potential conflict-of-interest scenarios.

2) Not participate in the specific decision where conflict may exist.

3) Ensure members submit annual lists of major activities and holdings for inspections.

4) Make the conflict known to those in superior positions.

48

What type of problem arises when a healthcare

executive knowingly allows the organization to

continue double billing?

1) An ethical problem for the healthcare executive, but may not

be grounds for dismissal if organizational policy is not clearly

stated.

2) An actual conflict of interest, even absent a direct economic

benefit to the healthcare executive.

3) An ethical problem for the employee if the healthcare

executive receives direct economic benefit.

4) An ethical problem if it clearly violates state or federal laws.

49

What type of problem arises when a healthcare

executive knowingly allows the organization to

continue double billing?

1) An ethical problem for the healthcare executive, but may not

be grounds for dismissal if organizational policy is not clearly

stated.

2) An actual conflict of interest, even absent a direct

economic benefit to the healthcare executive.

3) An ethical problem for the employee if the healthcare

executive receives direct economic benefit.

4) An ethical problem if it clearly violates state or federal laws.

50


AMA)








51

Support and further activities of clinicians, especially

Licensed Independent Practitioners (LIPs).

Cannot interfere in the LIP relationship with patients,

unless patients are at risk or the executive needs to

enforce decisions of clinicians who are performing peer

review or judging clinical competence.

Executives minimize LIP concerns regarding indepen-

dence and patient relations by working through the

professional staff organization (PSO) and the medical

director.

52

Process that reviews LIP qualifications.

Health services organizations are ethically and legally

obligated to determine if the LIP (i.e., MDs and DOs) is

qualified to have independent access to patients.

Depending on the state in which they reside, the

credentialing process may extend to dentists,

podiatrists, chiropractors, etc.

53

If an LIP is deemed incompetent to have privileges, the

practitioner must stop providing treatment and undergo a

review.

Ethical and Legal Obligations:

1) obligation to work to safeguard the “patient or

others served” from risk of harm

2) legal obligations to protect the patient from harm

as defined by statute and court decisions

54

The establishment of an appropriate credentialing

procedure for members of the medical / professional

staff should ultimately be a decision of the:

1) Entire medical / professional staff

2) Credentials Committee

3) Governing authority

4) Medical / professional Executive Committee

55

The establishment of an appropriate credentialing

procedure for members of the medical / professional

staff should ultimately be a decision of the:

1) Entire medical / professional staff

2) Credentials Committee

3) Governing authority

4) Medical / professional Executive Committee

56

The governing authority of a healthcare facility can

terminate the privileges of any member of the medical /

professional staff:

1) At any time if it follows its own adopted procedures

2) At any time with or without due process

3) Only if termination is recommended by the medical /

professional Executive Committee


professional staff

57

The governing authority of a healthcare facility can

terminate the privileges of any member of the medical /

professional staff:

1) At any time if it follows its own adopted procedures

2) At any time with or without due process


professional Executive Committee


professional staff

58


AMA)








59

“A member of ACHE who has reasonable grounds to

believe that another member has violated this Code has

a duty to communicate such facts to the Ethics

Committee."

VI. The Healthcare Executive's Responsibility

to Report Violations of the Code

ACHE Code of Ethics

(as amended by the Board of Governors 11/14/11)

60

ACHE members are obliged to bring to the attention of the ACHE

Ethics Committee any information that reasonably causes them to

believe there has been an infraction of the Code.

Alleged infractions of the code are reviewed by the Ethics

Committee, and this Committee makes a recommendation to the

Board of Governors, which has final authority.

The CEO sets the moral and ethical tone for the organization which

permeates the norms that govern the behavior of people in the

organization. Ethical leadership is critical to success as a

leader. Patients expect it, staff need it, and regulators demand

it.

The maximum penalty the College may impose is expulsion.

61

According to the ACHE Code of Ethics, what action

can the Ethics Committee take against a member after

a grievance procedure has been initiated?

1) Fine the member

2) Report the violation to the member’s employer

3) Issue a written reprimand to the member

4) Recommend expulsion of the member

62

According to the ACHE Code of Ethics, what action

can the Ethics Committee take against a member after

a grievance procedure has been initiated?

1) Fine the member

2) Report the violation to the member’s employer

3) Issue a written reprimand to the member

4) Recommend expulsion of the member

63


AMA)








64

Institutional Review Boards

1) purpose is to protect human rights

2) developed in direct response to research abuses early in the

20th century (i.e., experiments by Nazi physicians; the

Tuskegee Syphilis Study, a project conducted between 1932-

1972 by the US Public Health Service on black men in rural

Alabama)

In September 1978, the National Commission for the Protection of

Human Subjects of Biomedical and Behavioral Research issued

“The Belmont Report: Ethical Principles and Guidelines for the

Protection of Human Subjects of Research”

65

Report outlined three quintessential requirements for ethical

conduct of research:

1) Respect for Persons - recognition of personal dignity and

autonomy of individuals

2) Beneficence - obligation to protect persons from harm by

maximizing anticipated benefits and minimizing possible risk

3) Justice - benefits and burdens of research be distributed

fairly

66

Which one of the following conditions must be met for human subjects to be used in a medical research program?

1) No suitable animal model exists for use instead of people.

2) The research program has been approved by the medical staff.

3) The research program has been approved by the governing authority.

4) Risks should be clearly explained in understandable language to each individual subject

67

Which one of the following conditions must be met for

human subjects to be used in a medical research

program?

1) No suitable animal model exists for use instead of

people.

2) The research program has been approved by the

medical staff.

3) The research program has been approved by the

governing authority.

4) Risks should be clearly explained in understandable

language to each individual subject.

68

Purpose is to help you identify areas in which you are

on strong ethical ground, areas that you may wish to

examine the basis for your responses, and

opportunities for further reflection

No scoring mechanism

Can be found on www.ache.org (under “Ethics” link)

69

Vision Statement - framework for strategic planning…

“where do we want to go?”

Mission Statement - the purpose of the company or

organization…“why do we exist?”

Organizational Philosophy - that from which the

organization’s vision and mission arise; reflects the

organization’s values

70

Study Guidelines Learn the specific expectations found in ACHE’s Code of

Ethics

Become generally knowledgeable about the codes of other

major medical professional groups

Know the rights and responsibilities of patients

Learn the types and functions of various types of

committees that deal with ethical issues

Understand the concept of conflict of interest and be able to

apply it in operational settings

71

ACHE, Manual for the BOG Exam

QUESTIONS ??

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Jack Lynch, FACHE President & CEO Main Line Health …hlndv.ache.org/wp-content/uploads/sites/19/2016/01/... · · 2017-04-09Jack Lynch, FACHE President & CEO Main Line Health ...

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