Amanda Wilde (Host): Welcome to the Healthcare Executive Podcast, providing you with insightful commentary and developments in the world of healthcare leadership. To learn more, visit ache.org. I'm your host, Amanda Wilde. In this podcast episode, we are joined by Assistant Vice President at WellStar Health System and Founder of the Ethics Architect, Jason Lesandrini and Susan Reeves, System Chief Nurse Executive at Dartmouth Health. Together we'll explore the vital topic of ethics and healthcare organizations. Welcome to you both. Thank you so much for being here.

Jason Lesandrini, PhD, FACHE: Thank you.

Susan Reeves, EdD, RN: Thanks.

Host: Good to have you. Jason, starting with you, as someone who leads strategy and implementation of ethics initiatives, what would you say makes someone an ethical leader?

Jason Lesandrini, PhD, FACHE: Thank you very much, Amanda for having us today, and thanks Susan for being here with me and sharing this stage. Really excited to have this conversation and I think it's a great way to start it off, you know, what does it mean to be an ethical leader? And I started thinking about this a long time ago.

We tend to think about ethical leaders and look to people that we've sort of idolized over time. And so, you ask folks, you know, who do you think are ethical leaders? You hear a lot of people stand out, you know, Mother Teresa, Mahatma Gandhi, Martin Luther King, there's other folks.

And, so when you push and ask them what it is about those people, they'll start telling you oftentimes of characteristics about them, they're trustworthy, or they showed real concern and care for others, or they seem to be fair people. And I that's right. I think that is right.

I think there's one thing we've missed though. The other thing that really is part of being an ethical leader is about certain behaviors. So when we start with ethical leadership, we definitely talk about people having certain characteristics and personality traits. And I think Linda Trevino would call this sort of the moral person that each of us are.

And then there's this other thing which she calls a moral manager, and I think she's probably right about this, which is about behaviors. There's about set of key behaviors that we see ethical leaders do. And so during my time when I worked at the VA and and beyond, I started thinking a lot about what those behaviors were and they specified a number of them.

And I think there's more to add, but it's things like you know, how do you set expectations around clear ethical practices, right? What behaviors do you do with your team to do that? How do you demonstrate that ethics is a priority to them? How do you use the right incentives to drive behavior?

You know, how do you participate in ethical decision making? So it's not just that we have a certain set of characteristics, because I think we all have that a lot. Well, a lot of us have this, I don't want to say everybody has it, but a lot of us have these great characteristics, but it's also the way we act too.

So, thinking about being a moral person and being a moral leader, and when you combine those two things together, what I think you get I is, I think you get good ethical leaders.

Host: So as we're talking about key behaviors and actions versus characteristics or personality traits, Susan, you're a leader responsible for setting the strategic direction for nursing across the Dartmouth Health System. Can you break down for us a leader's ethical decision making process? What are the steps involved in your process?

Susan Reeves, EdD, RN: So Amanda, so important, to answering your question is always to understand that a lot of the decisions we make in our day-to-day work actually have ethical dimensions to them, and so the ability to apply the ethical decision making process to what seems like everyday decisions, staffing shortages, vendor selection, et cetera, et cetera.Many of those have ethical dimensions to them. And so, very easily relate to using an ethical decision making process.

All of us learned the problem solving method when we went to elementary school, and so the ethical decision making process is very, very similar. One usually starts out by making sure that there's just an excellent identification of the problem, and as some ethics authors put it, you gotta get the story straight and that means often talking to a lot of different people about their perceptions of what they think the challenge is that is in front of them. Next is to actually identify the exact ethical problem. Leaders face problems all the time, and sometimes people might actually characterize problems as ethical problems, but they're really legal problems or compliance problems or something like that.

So understanding what constitutes an ethical problem, is sort of part of that. This can actually, you know, emerge from having values in conflict, having violations of codes of ethics or codes of conduct. It can be policy and procedure violations. Oftentimes the very, hallmark of the fact that you've got an ethical challenge in your midst is the level of distress that an organization or a group is feeling about something. So, identifying the problem and then using some of the ethical theories and concepts to actually analyze the problem, come at it from different points of view, doing the most good for the most people, sometimes looking at an individual's rights, et cetera.

Exploring alternatives is an important part. So being really creative and thinking about what are the different ways that we might be able to move through this process.Actually completing the action, or recommending the response that you want to make.

And then finally, two things that are often overlooked, I think as part of this process is to step back and evaluate how did that go? Did the outcome produce what we were hoping that it would produce? Did the process work as well as we wanted it to work? And if not, how would we improve the next time?

This improve the next time is part of preventing ethical challenges and conflicts in our organization. So again, once you move through this and you really evaluate, there's the opportunity to see if you can't help this not happen again in your organization.

Host: So you're talking about preventing ethical challenges by having this strong model, but Jason, what are some threats to maintaining ethical behavior in a healthcare organization, and how do those threats affect the mission of an organization?

Jason Lesandrini, PhD, FACHE: Well, Amanda, the simple answer is people. That's the biggest threat is being a human. If you ask, me, and I, think what I mean by that is we're all wired in essence the same way. We all have the same kind of brain that functions in the same kind of way and can be subject to things we don't even recognize that we're doing.

Right. So, it could be things like external pressures of time. But it could even be even things that we don't see. So, there's a lot of research that's gone on to look at how our brains function, and I think the best way that I've ever seen conceptualized is Jonathan Haidt did this a number of years ago where he talked about our brains are like an elephant and a rider.

There's a large automatic process that goes on in our brains; that's sort of the elephant, right? And then there's this cognition or reason thing that sits on top of the elephant that's supposed to guide it. And, in the ideal world, that's what happens. We're here today talking about what it means to have ethics in an organization, build ethical cultures and ethical leaders, and that's great.

But what I think these kinds of conversations do is they speak to that rider. They're not speaking to the bigger animal that's in our heads, which is the automatic function, the way that we've learned things, the behaviors that we built; tying back to sort of what I was saying before. And so when I think about what's biggest threat, it's about how have we formed that elephant?

 It's been my experience that team members across an organization are looking to form that elephant when they onboard. And so they look for what type of training, what type of things, what actions do the leaders do in their organization and that's what they follow. So say for example, Susan brings me on to her team and I'm reporting to her, and you know, really energized being part of the organization.

And I see every day, Susan, I don't believe you'd do this, but I see every day Susan leaves 20 minutes early, right. And so what that does is that sets for me the tone of the behavior in the organization about, oh, well it time, it's sort of irrelevant. It doesn't really matter here. Like, you not to say she intentionally is trying to steal time, but time theft is okay and taking home things right.

She takes home, even small things from pencils to pens, and then it's TVs and whatever it may be. It sort of sets the way it is. Sorry Susan, I didn't mean to do that to you, but, that's sort of the idea. I think the biggest threat is making sure we're thinking with our teams, about. what stressors they come under to sort of Susan's point and about how their brains work, about really what's the science behind why people do the things they do. And then it ties in exactly to Susan says. Like, one thing we don't recognize is the stress that people are under. Time is, in my sense, and all the literature I've read is the number one predictor of whether someone is going to be able to see an ethics problem and how to respond to it.

Right? And so, yes, our leaders across the country, who are members of ACHE and outside are all under time pressures. But I think Susan's point about participating in a decision making framework gives you a second to pause. It says, let's just run through that real quick. Make sure I'm seeing it, seeing the options, seeing who the stakeholders are, you know, all the people who we're starting to think about and, I think that is the biggest threat.

There are outside pressures and everything that's going on, but, I don't think that's where it is. I think it's individuals and how we work to train those individuals, both training that rider that I talked about and training that sort of elephant that's underlying all of it.

Host: The culture around all of us.

Jason Lesandrini, PhD, FACHE: That's right.

Host: You mentioned responding to when there are lapses. Susan, if an organization has an ethical lapse, what steps must it take to resolve that issue and hold those accountable, and especially to regain trust?

Susan Reeves, EdD, RN: So I'm sure Jason would agree that we've both seen this done well and we've both seen it done poorly. So I'm going to focus on when it's done well. I think, what are the elements that are part of that? And, I would harken back to the decision making process is very similar. So when there's an ethical lapse, there's often tremendous emotion attached to that.

So, really key is to make sure that people are getting facts and people are getting the story straight. And the leader has a tall order, oftentimes in these situations. So, bringing some resources to bear, having an ethicist at their side as they think through how to respond to an ethical lapse.

I often say an ethicist is a gift that a leader gives themself. So if there's that ability to partner with an ethicist as you step through an ethical lapse and how to respond, I think that's important. But definitely thinking about, again, all of those stakeholders who might be impacted by that lapse.

And I also then think about the leader's responsibility around transparency. So, when I've seen this gone well, a lapse resolved well; it's when a leader can be as transparent as possible, recognizing that there's information obviously that doesn't belong in public conversation, but to really talk about the fact that they are aware that they have intervened.

And that again, they're taking steps to make sure that that lapse would not occur again. That means a leader often has to take responsibility for a culture that allowed a lapse. And again, talk a little bit about what they will do to shore up that culture, to make sure the lapse doesn't happen again.

It often takes a great deal of humility on the part of the leader, and sometimes it's just the same as with a medical error or any kind of error, sometimes you have to say, I'm sorry, that this happened. And so again, having someone attached to the leader to help them through these very emotional situations is very important.Jason, I don't know if you have other thoughts about that.

Jason Lesandrini, PhD, FACHE: I think you're spot on, Susan. I think that's exactly right. Now listen, I'm a little biased, working in the ethics space myself, you know, as you Susan. And so think that having resources available to team members to help address those things. I think the other thing that I would just add, and Susan said this, I'll just highlight it, is calling it what it is.

That we didn't live up to what we said we were as an organization. And I think Amanda and Susan, this gets to the point of this notion about, as you asked in the previous question about what does it mean to live up to our mission? Mission can't just be words on a wall, on a piece of paper that we pull out when it's time for the right PR event to happen.

That's not what that's about. That's not how I take it to mean. I don't think anyone who joins an organization to mean. And so when a lapse happens, what we need to do and respond with is, the reason this was a problem was because it violated something who we thought was integral to who we are as an organization.

Whatever those values, the mission may be, or the vision we might have. Thinking about the MVV, right? Always thinking about the MVV. Why is that lapse a problem? And then saying, just like Susan said right there, what are we doing to make sure we're correcting it and what are we doing to make sure that it doesn't happen again. So whether it's we need training, right? It's back to what I was saying before about we didn't put in the right place to enhance the culture. We didn't do what we needed to do to train the elephant, right? Or, maybe we were speaking only to the rider or only speaking to the elephant.

We need to make sure we're speaking to both and really just putting things in place. And then tying it back to at all occasions. I think this should be done with everything we do in healthcare is tying it back to who we are. We are in a special place and take care of special people in healthcare. People who are vulnerable and need something more than a lot of other spaces and a lot of other industries in the world.

And so it behooves us as leaders and organizations to say, well, we didn't live up to what we said we were going to be, who we profess to be. And here's what happened. Here's what we're doing to make sure it doesn't happen in the future, and we're really going to double down on our values.

Host: Well, Jason, to strengthen that transparency and organizational ethical integrity, what are some resources that healthcare organizations can provide to all staff to support ethical decision making? And you also mentioned training. What kind of training do you think should be included?

Jason Lesandrini, PhD, FACHE: We could spend a year on a podcast together about all of this. So I'm going to try and do my best to trim it down, but I think Susan started to pick out, and again, I know what perspective I come from, I'm just going to admit my bias here. I think healthcare organizations across this country should be employing ethicists. I think, it is a gift to the ethicist and as Susan says, is a gift to the leader. And I think there's value in that. And having someone who is expertly trained in ethics, who can help drive that work. I think in a lot of organizations we have ethics committees that, these ethicists either can be part of, or even if you don't have it, making sure that you have an ethics committee that's appropriately resourced and appropriately trained so that when they need to respond to things, they can respond to things.

And then I think there are a couple other things that we need to talk about. So training is one I'll get to in a second. I think we need to measure what's going on from an ethics perspective in the organization. I don't know a lot of organizations. I know there are a few that hint at doing it.

But really, how do we measure the ethical culture in an organization? And what are we doing to measure that? Not some of the other, you know, engagement surveys. Those are great. But they're not measuring sort of the ethics of the organization. We need to think about how are we measuring the ethics in the organization?

What does that mean to have an ethical culture? How do you do that? And then lastly, to your point, is about training. So one, I think there should be ethics onboarding for every team member who comes into an organization to make them aware of the resources that they have available to them. That the commitment to the values of the organization, the mission.

And I think a lot of leaders do that. And then I think there needs to be specialized training, with leaders on these topics about as Susan said. What framework do we use in the organization to make decisions, right? How are we training leaders to be aware of the problem that we pointed out earlier about, that we're going to have blind spots just because the way our brains work, right?

That we're going to have time pressures and how do we respond to those things? How do we ensure that we still live up to those values? And I think what leaders need is constant reactivation of that. It cannot be, and I don't know any other clearer way to say this. It cannot just be a CBL. It can't, it doesn't work.

It, doesn't lead to the behavior piece. CBLs are good and they address some things, but it's very hard to drive behavior through a CBL. And so I think we need to think about how do we actively engage our teams in actual practicing behavior, doing the behavior, not just reading or hearing about the behavior.

Susan Reeves, EdD, RN: I practice in a rural environment. So my health system sits in Northern New England and there are some, very, very small hospitals in very, very remote areas that we try and support. And so just a couple of other thoughts about resources.

We often, when we're talking about this, encourage hospitals and health organizations to think about what are potential other resources in their communities or their region that can be drawn in. So if they don't have the ability to have their own ethicist, are there colleges and universities perhaps that have a philosophy department or a professor who has ethics as their background and specialty who might be encouraged to come and work inside those organizations to facilitate some of the building of these behaviors and skill sets that Jason is referring to. And then, personally, one of the things I'm really interested in and have been talking in my own health system about, because we are rurally situated, is we have tele everything right now.

You can do tele emergency department care, you can do tele ICU, provided we have broadband service. There is the opportunity to export ethicist consultation through tele ethics, to different organizations. And I think we have now many ethics committees that are suggesting that could be a real contribution that our health system could be making, is to be able to export our ethics resources via this tele ethics mechanism, to be able to spread that.

Host: Yeah, the landscape is changing and we don't even know what changes the future might bring. Susan, finally, will you describe ACHE'S commitment to ethics and the ethical conduct of its members?

Susan Reeves, EdD, RN: One of the things whenever I'm kicking off a course or talking to a new group of leaders, that I work with, I often give as an assignment, you need to go in and explore the ACHE code of ethics and give them the website and so forth, but there's so much more. And so, I was in this morning to make sure my information was current.

In addition to the code of ethics, there's also tools where you can do self-assessments, ethics self-assessments as an individual, looking at areas where you might need to have some skill building yourself as a leader in the healthcare environment. There's many, many ethics resources. And then again, there's also policy statements, that are on the website available for everybody.

It's not behind any firewall or anything. They're just out there. And so things like how to create ethical cultures, policy statements on how to move through a reduction in force, what to do if you are confronted by an impaired healthcare executive and many, many more. So, really easy to navigate.

 If you type in ACHE or American College of Healthcare Executives and you move to the about ACHE tab and take our story and our commitments, it brings you to this just wealth of resources. So I think this is a commitment that ACHE makes to its community and its membership, to actually keep these resources updated.

And, probably the other thing I would just add is in the Healthcare Executive Journal that they publish every other month, they often have an organizational ethics column that Jason and I, often contribute to, to keep their membership aware of what are some of the more contemporary issues in healthcare ethics. So I think ACHE makes a tremendous contribution in this field and we're really lucky that they do.

Jason Lesandrini, PhD, FACHE: Read Susan's pieces, everybody. That's what we should go do. And I'll self plug mine too, but, definitely read Susan's pieces. I think the other thing that's really fascinating, about ACHE too, Amanda, is Deb Bowman.

So thinking about how she stands out for ACHE for ethics. She recently just wrote a piece. There's lots of things that come out through LinkedIn, social media through ACHE that are about this topic, about ethics, about living with your values, about challenging times, whatever, 10 years ago, 20 years ago, now, whatever. It's been constant through ACHE and the leadership of ACHE, sort of connecting back to those things. I've taught at Clusters, I've presented at Congress. There are lots of other places where folks can plug in and start to see more ethics stuff happening, just to stay abreast of the things that are going on in the field and, kudos to the commitment by ACHE for that.

Host: It is that key piece of continuing engagement.

Jason Lesandrini, PhD, FACHE: Yeah, that's right.

Host: Jason Lesandrini, Susan Reeves, thank you both for sharing your insights on ethics and healthcare organizations and all you're both doing to build ethical cultures.

Jason Lesandrini, PhD, FACHE: Thank you.

Susan Reeves, EdD, RN: Thanks, Amanda.

Host: For more information and further discussions, visit healthcareexecutive.org. This is Healthcare Executive Podcast from ACHE, the American College of Healthcare Executives.