H E C FORUM  2005 Springer.

2005; 17(1): 1-5. Printed in The Netherlands.

VALUES BASED DECISION MAKING IN HEALTHCARE

INTRODUCTION

JAMES J. MCCARTNEY, OSA, Ph.D.

Values based governance and management have been acknowledged by

experts as the “stuff” of which visionary companies are made (1). The two
articles that follow analyze some of the theoretical elements of values based
decision making, while this article will describe a process which has been
developed to help healthcare professionals implement values based decision
making in their facilities and systems.
The article by Ana Iltis discusses the importance of values based decision
making for establishing and maintaining organizational integrity and also for
maintaining (or improving) the financial well-being of healthcare
organizations. She discusses the importance of mission, the integration of
values based decision making into all aspects of a healthcare organization’s
life, and the importance of the development of a process for navigating
conflicts in interpretation of the mission that frequently occur.
The article by Mills and Spencer focuses on values based decision making
as a tool for achieving the goals of health care organizations. They see cost
containment and maintenance (or improvement) of quality of care as the two
most important goals of healthcare, and show how values based decision
making can assist in the achievement of both these goals. While their article
is interesting and helpful, many healthcare organizations also have
improving access to healthcare resources as one of their primary goals, and it
would be interesting to see how the authors might include this goal in their
analysis. Their essay recommends incorporation of values based decision
making in the critical elements of leadership and at all layers in the
healthcare organization.
For many years, I was an ethics consultant to several (religiously based)
health systems and institutions. During that time, I developed a practical
guide and process for implementing values based decision making, and I
1
2 Value Based Decision Making in Healthcare

would like to introduce the topic of values based decision making by sharing
it. I have presented this process to many boards of healthcare organizations
and have been involved with actually using the process on several occasions
at both the governance and management levels of healthcare organizations. I
have received positive feedback from professionals in many areas of
healthcare who have found the process helpful.
As background to this process, I emphasize that the research of Collins
and Porras (1; see also 2; 3; 4) has shown that visionary companies are those
that preserve their core values and core purpose even as they possibly
change almost everything else to compete more successfully. Core values
and core purpose are then defined as “organizational ethics,” which is
described as “the intentional use of values to guide the decisions of a group.”
Any values based decision process (i.e., organizational ethics process) must
assist decision makers in recalling how the organization describes itself in
terms of its mission and values, as well as clarifying what it should decide
about the particular issue facing it.
The characteristics of organizational ethics are:
1. proactive and not just reactive,
2. organizationally integrated and not isolated,
3. accountable according to measurable outcomes, and
4. oriented by institutional values.
The operating assumption of this process is that the healthcare
organization is based upon a set of core values and a core purpose that
should influence all decisions made by the organization. These decisions
significantly affect the people served, but, at times, involve multiple and
apparently conflicting values. The process of values based decision making
will demonstrate the vision and values of a healthcare organization in action.
Figure one is a schematic diagram of the values based decision making
process.
The first thing that must be noticed is the central vertical axis which
highlights issues, decisions, and goods. Every decision involves some issue,
and the decision rendered about the issue must generate some goods. This is
true for decisions in general, but values based decisions must also consider
specific inputs and outputs as part of the process that guarantee that the
values of the healthcare organization are adequately considered and
implemented.
With regard to the specific issue being considered about which decision
must be made, the issue itself must be clarified and adequately discussed
before any decision making process can begin. This can be done by looking
at the facts and data that make up the issue, considering the historical
relevance of the issue, and the people involved in the issue, carefully
 J. McCartney 3

considering any conflicts of interest that may be involved. It is my

experience that clarifying issues may be the most difficult (and important)
part of values based decision making because leaders tend to present issues
so that they are congruous with the decisions they think should be made.
This is a mistake, and those who are called upon to facilitate values based
decision making must insist that the issue be clarified objectively and
dispassionately before any decision regarding this issue is made.
Every issue may generate several possible decisions so that, in addition to
the goods produced by each possible decision, each decision itself must be
considered in the light of the institution’s mission and values. This can be
done by considering several inputs to the decision as well as the
consequences, not including the goods, that will come from any specific
decision made. Decisional inputs include the values and obligations of the
organization, legal and financial aspects of the decision, values of the local
church (if the healthcare organization is religiously based), and the values
and obligations of others. Some of the consequences of the proposed
decision must include its impact on the sponsors of the organization and the
reputation of the organization, its impact on employers and employees, its
impact on clinicians, its financial impact, its impact on patients and
residents, its impact on the local church (if the healthcare organization is
religiously based), and its impact on the local community (especially the
poor).
Finally, what goods the decision generates must be considered. These can
include, but are not limited to, the promotion of health or the compassionate
care of the dying, better stewardship of resources (human, financial,
environmental), promotion of the values of the Catholic tradition (if the
healthcare organization is Catholic), and finally, the proclamation and
promotion of organizational mission and values. When the impacts and
goods of the decision are adequately considered, often it will be recognized
that this potential decision is inadequate, and a different decision must be
considered. When this is the case, the same procedure should be used to
assure that whatever decision is made is indeed values based.
As previously mentioned, I have presented this process to healthcare
administrators and boards of trustees, and they have generally found it very
helpful. I have also been a facilitator of decision making in healthcare
settings and have used this process and it has worked very effectively. There
certainly could be other models which adequately allow values based
decision making to be accomplished, but I know from experience that this
one, mutatis mutandis, works very well. I invite you now to reflect on the
following two articles which discuss values based decision making more
theoretically to show its importance for healthcare decision making.
4 Value Based Decision Making in Healthcare

Figure 1: The values based decision making process.

REFERENCES
1. Collins J, and Porras J. Built to last: Successful habits of visionary
companies. New York: HarperBusiness; 1997.
 J. McCartney 5

2. Castañeda-Méndez K. Value-based management for healthcare:

Linking costs to quality and delivery. New York: Quality Resources;
1996.
3. Martin JD, and Petty JW. Value based management: The corporate
response to the shareholder revolution. Boston: Harvard Business
School Press; 2000.
4. O’Toole J. Leading change: The argument for values-based leadership.
New York: Ballantine Books; 1995.