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A Working Process Document Raises Questions for Dialogue and Self-Assessment

The Catholic healthcare ministry is at a challenging moment in its history. Not only is the ministry called to continue to be authentic to its own self, but the ministry also has the opportunity to communicate the richness and universality of its values to others.

In response to our members' genuine concerns, the Catholic Health Association of the United States (CHA) has prepared this document to support our members in the expression of their Catholic identity in new forms of healthcare service.

Themes in Catholic Identity
Catholic identity is a process and, as such, it has no ultimate answers, only questions that each organization must work through according to the dictates of persons, circumstances, mission, and values. It is the intent of this document, then, to raise questions about Catholic identity for your consideration as you enter into discussions with potential partners to create new relationships.

This self-evaluation process begins with asking how Catholic identity is expressed in your organization now. The process should lead to a clear definition of principles and values that are the concrete expression of your Catholic identity and which need to be part of the negotiation process.

To assist in this discernment, the document discusses four themes critical to Catholic identity: mission, sponsorship, holistic care, and ethics. Each theme is discussed separately, but none stands alone as more or less important, and they cannot be separated from one another. Together, they provide a rich tapestry reflecting the mystery of Catholic identity.

Each theme is briefly described, and some pertinent questions are supplied for your use in prompting dialogue on the elements of Catholic identity within your organization. The final section of this document emphasizes that Catholic identity issues must be deliberately provided for in your negotiating strategy. The section complements other guidance previously provided by CHA; it is not a comprehensive blueprint or operational manual, only the experience of some who have struggled with issues and have found solutions — more or less — for their own unique settings.

Foundational Values
The points raised in this document are grounded in values that are synonymous with being Catholic. This document focuses on the tradition of Catholic healthcare by using questions grounded in and coming from these basic values:

• Healthcare is a service and never simply a commodity exchanged for profit.
• Every person is the subject of human dignity, with intrinsic spiritual worth, at every stage of human development. Every person has a right to healthcare.
• People are inherently social; their dignity is fully realized only in association with others. Our social nature demands that the common good be served; the self-interest of a few must not compromise the well-being of all.
• Preferential option for the poor calls for particular commitment to the healthcare disenfranchised.
• Stewardship requires that we use natural and social resources prudently and in service to all.¹

Mission

The mission of the Church is to demonstrate God's love and saving power present in the world. This power, incarnated in the person of Jesus, is clearly seen in the Gospel. We witnesS Jesus touching, healing, and restoring persons to physical life. Then the meaning of life is expanded to include one's relationship with God and others and hope for life to come.

The mission of Jesus is alive and dynamic. It is not set in one period of time or in a single set of circumstances. Rather, the mission finds unique expression in all times and through a variety of people and institutional structures. The mission drives an entity to actualize its core values and philosophy. It is also a benchmark to evaluate authenticity and effectiveness. In new partnerships, mission should be the driving force by which decisions are made and structures and systems developed. A shared, compatible understanding of mission is essential to establishing new relationships.

QUESTIONS
Origins: Mission and Philosophy

• What purposes should you serve in today's healthcare environment?
• Why was your organization founded?
• What beliefs and values were most important to your founders? Which ones are most important to you today? Why?
• How does your organization understand itself in regard to the healing ministry of Jesus? Of the Church?
• Which of your foundational beliefs and values should be preserved in a new relationship? Why?
• What beliefs and values would help your staff to be committed to your organization in a time of transition?

Corporate Culture and Leadership

• What values shape your corporate culture? How are they consistent with the Gospel? How are they evident in policies and practice?
• How do potential partners show respect for your values?
• In what specific ways have potential partners demonstrated compatible values in their own corporate culture?
• How will your religious heritage continue to be expressed in the new relationship?
• How do your leaders shape the corporate culture of your organization?
• How do your leaders demonstrate flexibility toward entering into new relationships?
• How do your leaders express their commitment to your mission and values?

Mission and Community Needs²

• How does your organization assess community needs and meet them? How can your organization enhance its response to community needs? How will the new relationship meet those needs in the future?
• How has the community been involved in the assessment of needs and resources?
• In what ways have you integrated other community agencies in assessment and planning to build a healthier community?
• How will the interactive cooperation of community resources (service agencies, church communities) be optimized in the new partnership?

Vision for the Future

• What is your vision for the future of your healthcare ministry?
• What is the vision of the new relationship?

Sponsorship

As healthcare reform gradually changes healthcare delivery, sponsorship will change from control to influence. Traditionally sponsorship has emphasized a position of corporate strength and independence through ownership and control via reserved powers. Developing new relationships requires a presence that relies on the ability to influence. In order to influence, sponsors need to be clear about the purpose of new relationships, the desired outcomes, and the concrete elements that define the Catholic healthcare presence.

Sponsors must be able to articulate the non-negotiables for the Catholic ministry, yet be flexible to choose between total control and having some presence with the power to influence. The process demands a commitment to collaboration in order to make the transition to a cooperative healthcare delivery system.

QUESTIONS
Control/Influence

• What structures or processes will maintain Catholic control or influence?
• What will be the sponsor's role in a new relationship?
• What is the vision of the sponsor for the healthcare ministry, and how will it shape or be reflected in the new relationships?
• What means will be used to have access to influence (e.g., covenants, standards, standing committees, selection of leadership, board majority, supermajority, mediation, arbitration)?
• What values will be promoted in the new relationships, and how will they find expression?
• How will the proposed endeavor enhance the ministry aspect and not just the business aspect of providing healthcare?

Relationship to Local Church

• How are you keeping your local church authorities (especially the diocesan bishop or delegate) aware of ongoing developments in your organization and its relationships?
• Will alienation of property be necessary?
• Who are the essential people who need to be in dialogue before the initiation of new relationships?
• How has collaboration among Catholic organizations (e.g., Catholic Charities, parishes, and other healthcare organizations) been encouraged in order to create new relationships?

Holistic Care

Holistic care encompasses the relationship of emotional, intellectual, occupational, physical, and spiritual aspects of personhood throughout the entire process of healthcare delivery. Simply said, holistic care is sensitivity to the whole person, and not just to a disease or condition that requires medical intervention.

Humans are wonderfully whole in their creation and being. No aspect of the person can ever be considered apart from the totality of personhood. Both in self-assessment and in anticipation of new relationships, it is important to reflect on how the whole, unique person is and will be considered in your ministry.

QUESTIONS
Organizational Commitment to Holistic Care

• How do you understand holistic care, and how is it expressed in your organization's policies, procedures, and practices?
• Does your potential partner share your understanding and commitment to holistic care? How is that demonstrated?

Spiritual Care

• How is the spiritual care of persons integrated into your overall care program? How does it meet the needs of persons of all denominations?
• How is the nature of spiritual care defined and by whom?
• How is quality pastoral care supported, monitored, and integrated?
• How will the new relationship continue your commitment to spiritual care?

Support for Complementary and Alternative Methods of Care

• What opportunities are available for complementary and alternative medical methodologies and practices, especially as they relate to cultural diversity, personal preference, religious belief, and similar factors?
• Are there barriers to complementary and alternative methods of care? How can these be overcome?

Holistic Care within the Context of Social Illness

• How does your organization address factors such as homelessness, violence, unemployment, stress, alcohol, and drug abuse that contribute to ill health?

Ethics

Ethics is the discipline that seeks to answer the question: What is good and right for persons as individuals and as members of the human community? Ethics helps us understand how human beings should relate to self, others, and God in order to be fulfilled as human beings.

For Christians, ethical behavior means living our lives in accord with Gospel values, so ethics is never added on to or separate from anything else we do. Continuing analysis and reflection are essential to be certain that whom we claim to be is consistent with who we are in practice. Although the Catholic tradition is a faith tradition, we believe that Catholic teaching is consistent with human reason and insight. Catholic identity demands ongoing ethical analysis to ensure that the values at the heart of the Catholic tradition are expressed in daily operations at all levels.

QUESTIONS
Preliminary Considerations

• How have you demonstrated a commitment to ethical practices throughout your organization? Does the potential partner share a similar commitment? How is this determined?
• What role will the Ethical and Religious Directives for Catholic Health Facilities play in the new relationship?
• How will different ethical positions be respected in the new relationship?
• Have you defined your essential ethical principles? Does the potential partner understand and accept that there are some issues or values which are not negotiable?
• How effective is your ethics committee? Will the new relationship allow for its continued functioning? How will appropriate ethical reflection be guaranteed in the new relationship?

Social Ethics³

• As your organization provides healthcare services to individual members of the community, how does it give service to the community as a whole (how does it respond to the needs of the common good)?
• How will this capacity for community service be enhanced by the new relationship?
• Does your organization have explicit policies and internal mechanisms in place that ensure care of the poor and disenfranchised?
• How will a new partnership allow you to maintain your commitment to the poor and disenfranchised and advocate on their behalf?
• How will new relationships promote equal access for all to health services?
• What values influence your budget process? Does a potential partner share those values? How is that evident?

Corporate Ethics⁴

• How do your corporate policies and practices express the Church's tradition of social justice?
• How do your policies respect the rights of employees and give them a voice in shaping their work environment? How will a new relationship promote this?
• How do you encourage attainment of personal potential and support family life? Will a potential partner share similar commitments to employees?
• If work force reductions become necessary in a new relationship, what provisions will be made to ensure fair and just treatment of employees?
• How does your organization demonstrate a commitment to a culturally diverse work force?
• In what ways has your organization consciously promoted the welfare of the community through its business and investment practices?
• How does your organization promote stewardship and prudent use of resources? How will a new relationship affect your commitment to stewardship?

Clinical Ethics⁵

• How do you demonstrate respect for the sacredness of life at all stages of development? Will your potential partner share these same commitments?
• What policies ensure that life is respected across the life-death continuum (e.g., the life of the unborn, genetic services, reproductive and fertility services, life-sustaining intervention, informed consent, appropriate care of the dying)? How will the values on which these practices are based influence the new relationship?
• How are patient autonomy and respect for the legitimate role of the physician balanced in your present clinical practice? Will the same balance be present in the new relationship?
• How do your policies ensure your medical staff is committed to ethical practice and appropriate peer review?

Negotiating Strategy

Catholic Identity and Negotiating Strategy
The four essential expressions of Catholic identity — mission, sponsorship, holistic care, and ethics — must be deliberately provided for in the negotiating strategy when new healthcare relationships are being considered. If they are not, you may unwittingly compromise or exclude Catholic presence and influence in the new relationship.

There are four phases to a negotiation:

1. The preliminary phase, in which guiding principles and non-negotiable points are delineated
2. The prenegotiation phase, which identifies partners and defines the process for and elements of negotiation
3. The negotiation phase itself
4. The postnegotiation phase of ongoing evaluation and monitoring

All these phases offer challenges and opportunities for Catholic identity in changing times, but the time to plan the Catholic identity "non-negotiables" is in the first two phases. What follows are some points that should help to reinforce the Catholic identity issues in these aspects of a negotiating strategy.⁶

Preliminary Phase
It is important in the early phase that the sponsor and the top leadership of the system and the facility provide clear guidance and objectives. This will allow for good communication and should help prevent misunderstanding by employees, the community, and potential partners. Clear objectives will also allow the facility chief executive officer to be proactive and to move quickly when opportunities are present.

Points to consider are:

• Know yourself: Identify your core values.
• Assess your mission: Establish objectives and set parameters for new relationships.
• Define specific communication processes and participation roles that will be important in the next phase.
• Review Catholic identity aspects of corporate policies regarding real estate, incorporation, joint ventures, leases, alienation, etc.

Prenegotiation Phase
This may be the most important stage for maintaining and possibly expanding Catholic identity and influence as your healthcare ministry moves into new relationships. It is an opportunity to assess your strategic position in the community and your role in its future. Consider the following suggestions:

• Identify the distinct gifts you bring to a new relationship.
• Know the community and envision your organization's role in its healthier future.
• Develop criteria for evaluation of potential partners.
• Identify a potential partner list.
• Interact with potential partners to share visions, share history and traditions, and share values.
• Approach the chosen partner with confidence and mutual respect.

Secure Negotiations
These two phases should be completed thoughtfully, considering these points and the earlier questions. If this is done, you should be able to engage in negotiations secure in your understanding of your Catholic identity and confident that its unique, essential aspects — as lived out in your organization-will not be compromised for the future.

NOTES

1. See Setting Relationships Right: A Proposal for Systemic Healthcare Reform, Catholic Health Association, St. Louis, 1993.
2. CHA's vision for new relationships in healthcare is rooted in a commitment to health for all the community.
3. Social ethics seeks to establish among the members of the human community reciprocal relationships. To do this, social ethics reflects specifically on the rights and responsibilities that members of the human community have in relationship to the common good. The common good embraces all the material and spiritual goods that are necessary for persons to live a decent life and fulfill their human destiny.
4. Corporate ethics evaluates the ethical dimension of decisions, policies, and structures that routinely facilitate the management of a healthcare organization's day-by-day operations. Corporate ethics seeks to promote just relationships among healthcare organizations and their patients, employees, and the community they serve.
5. Clinical ethics deals with issues that originate in the clinical setting where healthcare is provided. It is a specialized field that includes (but is not limited to) issues related to human genetics and reproduction, treatment decisions at the beginning and end of life, and research involving human subjects.
6. This is not an attempt to provide general guidelines for negotiations. The discussion is limited to an emphasis on providing for Catholic identity in the negotiation planning. For information on other aspects, see, for example, James L. Elrod, Jr., Geoffrey B. Shields, and Judson T. Bergman, Merging Health Care Institutions: A Handbook for Buyers and Sellers, American Hospital Association, Chicago, 1987.

Juliana Casey, Food for the Journey: Theological Foundations of the Catholic Healthcare Ministry, Catholic Health Association, St. Louis, 1991

Corporate Ethics in Healthcare: Models and Processes, Catholic Health Association, St. Louis, 1991

The Dynamics of Catholic Identity in Healthcare: A Working Document, Catholic Health Association, St. Louis, 1987

A Handbook for Planning and Developing Integrated Delivery, Catholic Health Association, St. Louis, 1993

Healthcare Ministry in Transition: A Handbook for Catholic Healthcare Sponsors, Catholic Health Association, St. Louis, 1993

James E. Hug, ed., Dimensions of the Healing Ministry, Catholic Health Association (with the Center of Concern), St. Louis, 1993

Issues in Collaboration and Joint Venturing, Catholic Health Association, St. Louis, 1986

Philip S. Keane, Health Care Reform: A Catholic View, Paulist Press, Mahwah, NJ, 1993

Mission Integration in Catholic Healthcare — A Guide to Assessment and Mission Integration in Catholic Healthcare: A Descriptive Analysis, Catholic Health Association, St. Louis, 1991

No Room in the Marketplace, Catholic Health Association, St. Louis, 1986

Physician-Hospital Joint Ventures: Ethical Issues, Catholic Health Association, St. Louis, 1991

The Search for Identity: Canonical Sponsorship of Catholic Healthcare, Catholic Health Association, St. Louis, 1993

Setting Relationships Right: A Proposal for Systemic Healthcare Reform, Catholic Health Association, St. Louis, 1993

Social Accountability Budget: A Process for Planning and Reporting Community Service in a Time of Fiscal Constraint, Catholic Health Association, St. Louis, 1989

National Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Facilities, U.S. Catholic Conference, Washington, DC, 1971 (Catholic Health Association reprint, 1992)