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Gray Matters

Health-Care Firms Realizing Need to Clear Up Ethical Fuzzy Areas


While caring for a patient, a nurse notices that potentially hazardous material has been thrown into the hospital room's trash can. But the nurse figures that trash disposal is not part of her job and ignores the problem. Later, that trash is taken out with the nonhazardous garbage.

What should the nurse have done?

She should have done or said something to make sure a biohazard container was in the room, according to a scenario given to employees at Tenet Healthcare Corp., the country's second-largest for-profit hospital chain. Whether she likes it or not, every employee must take responsibility for such lapses.

These days, Santa Barbara-based Tenet, like many other hospital companies, is giving its employees a lot of food for thought regarding ethical dilemmas. And it's Neil Hadley's job to make sure employees learn how to make the right decision involving patient care, conflict of interest and fraud, among many other issues.

Hadley, vice president of ethics and business conduct, launched and began running an ethics program for Tenet in the mid-'90s. It has become a model program for the health-care industry, which has been plagued by scandals and beset by a crisis of confidence.

Now, many hospitals and health-care companies in different parts of the country are setting up ethics programs.

"We've gotten many calls from other people who want to pick our brain," Hadley said. "They're jumping on the bandwagon."

Another high-profile program is at Columbia/HCA Healthcare Corp., the nation's largest for-profit hospital chain. Since last year, Columbia has been at the center of a federal investigation into Medicare fraud and physician payments for patient referrals. Last fall, the company hired ethics veteran Alan Yuspeh as a senior vice president to create and oversee an ethics and compliance program. Columbia has since started training more than 500 designated hospital and surgical center ethics officers in its facilities nationwide.

Other health-care facilities that are not currently under investigation are initiating programs because the federal government has become more aggressive in investigating fraud. If a hospital has an existing regulatory-compliance program, penalties from an investigation can be reduced.

Tenet has had its share of troubles too. Its predecessor company, Santa Monica-based National Medical Enterprises, settled federal fraud charges in its psychiatric hospital division in the mid-1990s. As part of the settlement, Tenet agreed to develop its ethics program. It's coming in handy. In July, OrNda HealthCorp, which Tenet had acquired just months before, agreed to pay $12.6 million to settle federal claims that several of its hospitals paid physicians for Medicare patient referrals.

Although these programs start with regulatory compliance, they often don't end there. Billing problems, financial conflict of interest, harassment and staffing levels all can fall under the ethics umbrella. And they all ultimately affect quality of care if resources are diverted from patient care.

"To have just a compliance-driven program will not ultimately be successful," said W. Michael Hoffman, executive director of the Center for Business Ethics at Bentley College in Waltham, Mass. "Ethics without compliance is a program without teeth. Compliance without ethics is a program that employees will not buy into."

There is considerable variation from one health-care company to another in these programs. And there is no agreement in the industry about what ethics means.

"Professional organizations are trying to develop a common ground," said David C. Blake, executive director of the Center for Healthcare Ethics in Orange. "So far, their members are so diverse that it's been hard to come to an agreement."

People who gravitate to health-care ethics include doctors, lawyers, theologians and community activists as well as hospital administrators. Each group tends to have different priorities. So far, there is no defined path for becoming an ethics officer. Bentley College and a few other institutions have formal programs for health care and other industries. But most people enter the specialty mid-career and beyond.

Columbia's Yuspeh is an attorney who was coordinator for the Defense Industry Initiative on Business Ethics and Conduct, a major effort by 48 defense contractors to develop ethics and compliance programs.

Hadley was a hospital administrator at Tenet tackling special corporate projects when he was tapped for the job, possibly the first full-time ethics position in a major health-care company.

With no blueprint to follow, he built Tenet's ethics program from scratch. It starts with a code of conduct that is issued to every employee. And everyone must go through an ethics training program within weeks of joining the organization and take refresher courses every year after that. The training includes discussions of conduct standards and case studies taken from the company's toll-free ethics hotline.

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