Ethical Leadership and Employees' Perceptions About Raising Ethical Concerns to Managers in the Veterans Health Administration.

Background: The willingness of employees to proactively give voice to their concerns, including ethical concerns (ethics voice), is critical to improving organizational performance and integrity. In health care, speaking up is vital to ensuring a delivery system centered on patient safety and quality, including ethics quality. In this study, we explored whether ethical leadership practices contribute to employees' willingness to raise ethical concerns to those in the organization who have the authority to take corrective action. Methods: We conducted a secondary analysis of 2014 IntegratedEthics Staff Survey data administered to a random sample of 50% of VA health system staff. The data we used reflected responses from 42,412 employees who were associated with 141 administratively defined medical centers that encompass more than 1,400 sites of care delivery and VHA administrative program offices. The response rate to the survey was 29.4%. Results: Employees positioned higher in the organizational hierarchy were more comfortable raising ethical concerns than lower ranked employees. Ethical leadership practices, and especially those that created an expectation of trust, follow-through, and fair treatment, made it more likely that employees would raise ethical concerns with managers. Conclusion: Speaking up about ethical concerns is essential to the delivery of high-quality patient care and is enabled by managers who embody ethical leadership practices. Ethics programs can help create favorable conditions for raising ethical concerns by providing managers and supervisors with ethical leadership coaching, recognizing power differentials, and modeling more egalitarian communication practices. More research is needed to understand how employees conceptualize ethics voice and to assess the comparative effectiveness of different methods of encouraging speaking up about ethical concerns in health care organizations.

Assessing the quality of VA Human Research Protection Programs: VA vs. affiliated University Institutional Review Board.

We compared the Human Research Protection Program (HRPP) quality indicator data of the Department of Veterans Affairs (VA) facilities using their own VA institutional review boards (IRBs) with those using affiliated university IRBs. From a total of 25 performance metrics, 13 did not demonstrate statistically significant differences, while 12 reached statistically significance differences. Among the 12 with statistically significant differences, facilities using their own VA IRBs performed better on four of the metrics, while facilities using affiliate IRBs performed better on eight. However, the absolute difference was small (0.2-2.7%) in all instances, suggesting that they were of no practical significance. We conclude that it is acceptable for facilities to use their own VA IRBs or affiliated university IRBs as their IRBs of record.

Conflict of interest issues pertinent to Veterans Affairs Medical Centers.

Conflicts of interest exist when an arrangement potentially exerts inappropriate influence on decision making or professional judgment, or is perceived to do so, and can thus damage the public trust and undermine the integrity of those decisions. Concerns regarding financial conflicts of interest in the medical arena have reached their height as of late, given that physicians now function in a milieu of complex and delicate relationships with pharmaceutical, biotechnology, and medical device industries. Even when such relationships do not correlate with actual compromise of judgment or patient care, it threatens the credibility of both the health care professional and the institution because of the social perception of the effect of these relationships. Although most institutions in the Western world set forth a code of ethics and conflict-of-interest policies to be followed under threat of termination, the Veterans Health Administration (VHA) presents itself as a unique environment in which conflicts of interest are subject to governmental laws, violation of which may not only result in employment-related discipline, but may be sanctioned by civil and criminal penalties. Moreover, these provisions are developed by a national authoritative organization rather than being institution-specific guidelines. Given that many academic physicians working within the VHA may also have a component of their practice in a University setting, it becomes important to understand the differences in policy between these contexts so as not to threaten the public trust in the veracity of decisions made and, therefore, maintain the integrity of the relationship between physician and patient. This article will review aspects of conflict-of-interest policies in the realm of research, financial relationships, foreign travel, and vendor contracting that are particular to the VHA and make it a unique environment to function in as a physician and scientist.

Priority setting and the ethics of resource allocation within VA healthcare facilities: results of a survey.

BACKGROUND: Setting priorities and the subsequent allocation of resources is a major ethical issue facing healthcare facilities, including the Veterans Health Administration (VHA), the largest integrated healthcare delivery network in the United States. Yet despite the importance of priority setting and its impact on those who receive and those who provide care, we know relatively little about how clinicians and managers view allocation processes within their facilities. PURPOSE: The purpose of this secondary analysis of survey data was to characterize staff members' perceptions regarding the fairness of healthcare ethics practices related to resource allocation in Veterans Administration (VA) facilities. The specific aim of the study was to compare the responses of clinicians, clinician managers, and non-clinician managers with respect to these survey items. METHODS: We utilized a paper and web-based survey and a cross-sectional design of VHA clinicians and managers. Our sample consisted of a purposive stratified sample of 109 managers and a stratified random sample of 269 clinicians employed 20 or more hours per week in one of four VA medical centers. The four medical centers were participating as field sites selected to test the logistics of administering and reporting results of the Integrated Ethics Staff Survey, an assessment tool aimed at characterizing a broad range of ethical practices within a healthcare organization. RESULTS: In general, clinicians were more critical than clinician managers or non-clinician managers of the institutions' allocation processes and of the impact of resource decisions on patient care. Clinicians commonly reported that they did not (a) understand their facility's decision-making processes, (b) receive explanations from management regarding the reasons behind important allocation decisions, or (b) perceive that they were influential in allocation decisions. In addition, clinicians and managers both perceived that education related to the ethics of resource allocation was insufficient and that their facilities could increase their effectiveness in identifying and resolving ethical problems related to resource allocation. CONCLUSION: How well a healthcare facility ensures fairness in the way it allocates its resources across programs and services depends on multiple factors, including awareness by decision makers that setting priorities and allocating resources is a moral enterprise (moral awareness), the availability of a consistent process that includes important stakeholder groups (procedural justice), and concurrence by stakeholders that decisions represent outcomes that fairly balance competing interests and have a positive net effect on the quality of care (distributive justice). In this study, clinicians and managers alike identified the need for improvement in healthcare ethics practices related to resource allocation.

Confessions of a bedside rationer: commentary on Hurst and Danis.

Samia Hurst and Marion Danis provide a thoughtful framework for how to judge the morality of bedside rationing decisions. In this commentary, I applaud Hurst and Danis for advancing the level of debate about bedside rationing. But when I attempt to apply the framework to my own clinical practice, I conclude that the framework comes up short.