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ethics, ethics orientation, health services organizations, organizational integrity



  1. Proenca, E. Jose


Abstract: Increasing scrutiny of ethical misconduct by federal and state agencies has prompted health services organizations to adopt codes of ethics and institute legal compliance programs. However, there is little understanding of the impact of ethics programs or the manner in which program elements act to enhance organizational integrity. This study examined the effect of five ethics program elements on organizational integrity and the mediating role played by ethics orientation in this relationship. It found that program elements influence organizational integrity by engendering among employees a values orientation, a compliance orientation, or both. Furthermore, program elements that induced both orientations have a larger impact on integrity. These findings have important implications for health services managers involved in designing and implementing an ethics program.


The Federal government's increasing emphasis on combating fraud, waste, and abuse has made it imperative for health services organizations to foster ethical behavior among their staff. These organizations operate in a unique environment, characterized by the tension between care and profit, and imposing on managers and staff enormous pressures for cost reduction, profit generation, and quality enhancement. Highly publicized cases of upcoding and inappropriate billing, unnecessary procedures, problem cover-ups, and denials of access and coverage have raised concerns that some health services employees might be succumbing to these pressures by making unethical, and often illegal, decisions. Such concerns have prompted calls for adoption of formal ethics and compliance programs by health care organizations.1,2


The pressure to adopt ethics programs comes from guidelines issued by the United States Sentencing Commission. These guidelines increased penalties for organizations convicted for illegal behavior but called for reduced fines and sentences for offenders that had made formal, proactive efforts to manage ethics and ensure legal compliance.3 These efforts include the development and communication of ethics policies, oversight and enforcement of compliance by a senior manager, and response to violations. Medicare regulations governing billing, cost reports, self-referrals, and kickbacks also suggest the need for ethics initiatives that will identify and address concerns related to documenting medical necessity, unbundling charges, secondary player regulations, and repayment of credit balances.1


It has been suggested that an organization's ethics program should include certain key elements such as a formal code of ethics that articulates an organization's expectations regarding ethics, ethics personnel who are charged with developing ethics policies and evaluating their effectiveness, an ethics communication system such as an internal hotline to report violations, an ethics training program that helps employees recognize and respond to ethical issues, and an audit or disciplinary process aimed at monitoring and addressing unethical behavior.1,4 While some of these program elements, such as ethics codes, have been widely adopted, there is still great variability in the extent to which the others have been implemented.5 Furthermore, little is known about the effectiveness of program elements, the process by which they affect ethical decision-making and ethical behaviors by organization members, or their relative impact on organizational integrity.6-8 Without such knowledge, health services managers would be hard-pressed in justifying the allocation of scarce resources to ethics programs or in deciding which of the many available elements to include in their program.


The purpose of this research is to investigate the relationship between ethics programs in health services organizations and employee perceptions of organizational integrity. Specifically, this study conceptualizes and tests the mediating effect of ethics orientation on the relationship between the five common ethics program elements-audit systems, internal ethics hotlines, training programs, ethics officers, and importance assigned to ethics as an organizational value-and the degree of organizational integrity perceived by employees. It also examines the relative influence of program elements on organizational integrity. Managerial implications for health services organizations are discussed.