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The Common . . . WHAT?

Medical Staff Affairs Monthly, December 10, 2008

Whatever happened to the concept of the common good? You know, that 2,000-year-old notion formulated by Plato, Aristotle, Cicero, and others. The concept is that there are certain general conditions that, when in place, are equally to everyone's advantage. Absent a common good, the alternative is the unfettered reign of basic human nature characterized by behavior promoting only self-interest and self-preservation. The current economic and social meltdown in the United States and abroad can be viewed through this filter. There has been rampant self-interest from Main Street to Wall Street and back again. It has been characterized by trying to get as much as possible for as little as possible combined with a dose of selfishness, greed, and avarice and has led to a significant recession. The labor statistics for the United States for November 2008 indicated a loss of 534,000 jobs in one month and the rate of mortgage foreclosures is at an all time high. There clearly are personal consequences to this unbridled individualism, lack of mutual accountability, and absence of the common good.

But let's bring it even closer to home. Daniel Callahan, a nationally respected bioethicist, says today's healthcare crisis requires replacing the current ethic of individual rights with an ethic of the common good. On a societal level, this involves an analysis of all the stakeholders—patients, payers, legal system, regulators, and providers. The following will focus on providers working in hospitals across the country.

Most U.S. hospitals have a governance and leadership structure that is a three-legged stool: a board, a CEO/executive team, and a medical staff. Each group has a fiduciary responsibility. The term "fiduciary" is often defined narrowly to mean financial accountability. Here, however, the term is being used as defined in Black's Law Dictionary, namely, "a person having the duty created by his undertaking to act primarily for another's benefit in matters connected with such undertaking."

The board has the ultimate fiduciary responsibility to ensure that financial, quality, and strategic targets are met consistent with the mission, vision, and values of the organization. The board does not manage, end-run, or enter conflicts prematurely. Individual board members have a duty to care, a duty of loyalty, a duty to carry out the hospital's mission and a duty to comply with the law. Individual directors don't violate confidentiality, undermine the board, hide conflicts of interest, represent constituencies, or participate in management. How does your board do in navigating this fiduciary channel?

The CEO has a fiduciary responsibility to the organization to run and manage it to meet the targets, strategies, and vision set by the board. The CEO acts in the best interest of the organization and not him- or herself. Management and executive decisions should be based on the common good of the organization as opposed to just padding one's résumé for the next job. How does your CEO stack up performing this fiduciary common good?

The physician has a fiduciary responsibility to the patient to make decisions in the best interests of the patient. Decisions should not be made solely to economically or otherwise benefit the physician. As a member of the organized medical staff, there is a further fiduciary responsibility to be mutually accountable to each other for monitoring and improving the quality of care that is primarily dependent on the performance of individuals granted privileges. This requires a well-designed and well-executed credentialing, privileging, and peer review process clearly articulated in policy, followed consistently in all areas, and uniformly applied and enforced through setting of expectations, measurement, and giving physician feedback. How does your medical staff measure up to this fiduciary expectation?

Some hospitals struggle with imbalances between individual interests and the common good on a board, CEO, or medical staff level—sometimes on all three. The lesson to be learned from the national economic crisis is that there is a price to pay and very real consequences when self-interest rules. Progressive and successful organizations proactively educate and train board members, executives, and medical staffs on best practices of leadership and governance and then monitor their performance over time.

The desired goal is to avoid the "tragedy of the commons." Garrett Hardin presented this idea in a 1968 article in the journal Science. The article describes a dilemma in which multiple individuals acting independently in their own self-interest can ultimately destroy a shared resource. In Hardin's article, it was multiple sheepherders depleting the grass on the common land so there was nothing for anyone to eat. In your world, it might be a board or a CEO or a medical staff or all three destroying the shared asset of the hospital. If you have not recently performed an analysis, education, and training about governance best practices, perhaps consider giving your organization a holiday gift and doing one in 2009.

Until next time, be the best that you can be and have a safe and happy holiday.

William K. Cors, MD, MMM, FACPE, CMSL
Vice President Medical Staff Services
The Greeley Company

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