Values based decision making: a tool for achieving the goals of healthcare.

The recognition that the success of the healthcare organization depends on its achievement of two interrelated goals is a relatively recent phenomenon. In its mid-history the healthcare organization was largely able to ignore cost issues. In its latter history, many would argue that it ignored its quality goals as it pursued its cost goals (15). Either approach, given declining revenues and a competitive landscape, is incompatible with continued responsible operation. If this is true, then tools that were appropriate when the healthcare organization was focused on the achievement of one or another of these goals are not adequate as the healthcare organization seeks to achieve both goals together. Thus, new perspectives and new tools must be found that help the organization address two intimately related but sometimes conflicting goals. Values based decision-making can be the perspective needed, and organization ethics is one tool that can be of use in supporting it within the institution. But there are caveats. In order for values based decision-making to be effective, leadership must take an active role in promoting its use. It must relinquish a degree of control and it must begin to trust its stakeholders to make decisions within the context of the organization's values and goals. This can be extremely difficult, as control by senior management is often seen as the only effective means of ensuring that correct decisions are made. There are additional difficulties in the healthcare organization. Control rests within two groups and the healthcare organization is operating in an environment in which variance elimination is emphasized as a means of controlling costs. This may be an appealing notion for revenue strapped healthcare organization leaders, but it implies greater control exerted by managers, not less. Relinquishing any degree of control is a frightening prospect, but it has been done successfully. An excellent example of leadership encouraging decisions based on values was presented by a unit administrator frustrated by the hierarchical structure and ponderous rituals of a traditional intensive care unit. Invoking a management tool called "the balanced scorecard" (which recognizes the multiplicity of goals and values in any organization) he identified the goals and values of the unit, and with the help and input of his staff he restructured it into functional multidisciplinary "teams" organized around tasks and goals which were based on values. The transformation of identities of unit members from their job description to their accomplishments improved both the efficiency of the unit and its morale--as well as resulting in cost savings. In this example teams had to learn to work together, collaborate and disregard the fear of doing things differently. Staff had to be motivated and feedback was necessary to ensure goals rather then rules were being meet. The balanced scorecard was implemented with mechanisms to support the communication and collaboration necessary to achieve the goals of the unit. The experiment was successful, but only because leadership recognized that multiple goals and multiple values were involved, that were explicitly articulated with the priority of excellent care. But once leadership was sure that "shared vision" existed leadership was able to trust staff to make appropriate decisions to realize that vision.