Leaders in Catholic health care often express their commitment to make decisions consistent with the organization's mission and values. At times, they indicate a need for guidance, especially when questions regarding balancing stewardship and care for the poor and vulnerable arise. For the biggest of decisions, those which have a significant impact on our patient population or our associates, or those which have big financial and cultural repercussions, Ascension developed an Organizational Ethics Discernment Process (OEDP). While an OEDP is an opportunity for integrating mission, values, and ethical principles into decision-making, the full process is time and labor intensive. It typically involves weeks of preparation, a full-day meeting with many leaders, and the creation of a comprehensive report describing the decision made and process to get there. These full discernments are critical for making mission- oriented decisions on a large scale, but they can only be used for decisions having the most significant impact on associates and the patients we serve.

Every day, however, leadership teams are making decisions that affect how we live our mission, even if they involve a smaller set of stakeholders and don't justify mobilizing the significant resources of an OEDP. Nonetheless, a commitment to mission means that every decision at every level should be compatible with the values of the organization. In what follows, I will share a Values-Based Decision- Making Guide that can be used for systematic integration of mission, values, principles of Catholic Social Teaching, and aspects of spiritual discernment into day-to-day conversations in the boardroom.

This tool was developed when a local leadership team realized the need to have a systematic way of addressing values in every decision they make. The leadership team asked for guidance from ethics because they were feeling the tension between the need to make hard decisions for the sake of stewardship of resources, and a commitment to care for the poor and vulnerable. The result of the collaboration was the Values-Based Decision- Making Guide, a series of eight questions intended to help leadership teams enter into an ethical decision-making process. This tool is based on the more extensive OEDP, distilling what is normally a long conversation into succinct questions for consideration. The whole conversation is designed to take between 30 minutes to one hour. While having an ethicist present to facilitate is helpful, the tool is designed to not require ethics expertise present.

An overview of the Values-Based Decision- Making Guide follows:

Values-Based Decision-Making Guide

Reflection

Level setting and information gathering

1. Why is the decision difficult?
2. Do we have all the information we need to make this decision now?
3. Do we have input from the stakeholders who will be affected by the decision?

Integrating values and principles

1. How does this decision connect to service of the poor and vulnerable?
2. What creative alternative solutions have been explored?
3. What values and principles underlie the decision?

Follow up and implementation

1. How does the team feel about the decision being made?
2. What is the best way to implement the decision, being sensitive to all stakeholders?

Before engaging in this process, it is particularly important to reflect in preparation for the conversation ahead and to pray for a spirit of discernment. The tool itself begins with acknowledging the ethics dilemma by asking why the decision is difficult. The team may be experiencing ambiguity about the ethically optimal course of action. If a decision has already been made, it may result in difficult consequences for some stakeholders and there may be concerns about how to implement that decision. The team will likely be thinking about the tension between competing goods, and it should be stated. Second, as in any decision- making process, participants should stop to consider if there is any essential information still needed. Stakeholders who are not present should be given the opportunity to provide input. When a leadership team is making a decision on behalf of a unit or a service line or a center, to practice subsidiarity they should make sure to have that representation.

Only then can conversation shift to how the decision aligns with the organization's values and principles. Participants are encouraged to discuss the challenge to care for the poor and vulnerable and the role of good stewardship of resources. They are asked to consider if they have given enough time to exploring creative options, as creativity is one of Ascension's values often exercised during ethics conversations. The printed version of Values- Based Decision-Making features text boxes, which highlight definitions of preferential option for the poor, creativity and stewardship, to keep those concepts on their minds as the discussion occurs.

The conversation ends with a distilled version of a "Testing the Spirit" exercise, wherein participants are asked to place how they feel about the decision on a continuum of desolation to consolation. They could consider how confident they are that the decision being made is the right one. If there is desolation, they are encouraged to discuss what might need to change to feel more confident in the decision. Finally, they consider the best way to follow through and implement, being sensitive to the needs of stakeholders affected.

Before recommending that it be used regularly or introducing the tool to other teams, it was piloted with the leadership team as a part of a retrospective review of a recent decision. They reexamined their original decision- making process through this framework, looking to identify how their conversation or decision would have been different if they had a systematic way to address the ethical dimensions of the decision and integrate values. A few key changes were identified. First, they invited leadership from the unit affected by the decision to be present for the retrospective conversation. Those stakeholders greatly appreciated having been included. Second, they noted an increase in discussion on the impact on poor and vulnerable persons, which had not been as emphasized previously. As importantly, they were able to highlight what went well in the initial conversation. The team had exercised great creativity in finding a solution for a population of patients who were affected by the decision, and their implementation and communication plan was strong.

It is important to note the cautions and limitations of use of a tool like this. First, before introducing a tool like this, a facilitator should ensure that participants understand that using this tool does not constitute a "discernment," a term that should be reserved only for when the full Organizational Ethics Discernment Process is implemented. This tool is intended to increase the consideration for values into the decisions that are being made every day, and is not an alternative to a full discernment, nor is it intended to replace ethics consultation. Second, one reason why this tool worked so well was because a few key leaders on the team had been through a formation program. They were able to explain concepts and principles to leaders newer to Catholic health care. Openness to use of a tool like this, as well as its success, is dependent on the leaders' willingness to spend time exploring how ethical decisions are made, which comes from good formation. While a Values-Based Decision-Making tool can't replace the transformation of hearts and minds that comes through formation, the process does have formative elements. Later feedback from individuals from this leadership team indicated that the retrospective conversation used was an exceptionally transformative experience for them personally.

Ideally, after practicing the process several times, leaders would not need to go through it step-by-step and will have internalized the concept behind values-based decision-making into their normal processes. Ultimately, it is less important to be referencing a tool and answering eight questions than it is to have integrated mission and values into hearts and minds, and this tool can be used as a step along that journey to growth.