 Alright. Well good morning. I'm both honored and excited to be in front of this group today. I'm not going to stand behind the podium. The bio is just read by Chris. I always like to say there's a bio behind the bio or story behind the story. So I'm going to give you two snapshots that really uncover who I am. First grew up in Queens, New York. Any Metz fans here? Alright. Usually doesn't go over well in Boston. Goes over like a lead balloon in Colorado, I'll tell you that much. So I grew up really poor actually in Queens, New York. My dad graduated only fifth grade. My mom high school. We grew up eating what I affectionately call nothing sandwiches. There was nothing in it. Maybe a little mayo. It wasn't Hellman's. So I say that to say that I think it inspires a certain notion of empathy when you grow up in that way. Different from sympathy, right? Sympathy you feel sorry for someone's plight. Empathy is you feel that person's situation. You can put yourself in their position in ways that inspire action. So you'll see that today in my presentation. Second, I think that I'm a guy who has a JD and an MDiv. So I feel like I always have to explain that. People always kind of ask me and they peer, they close their eyes a little bit and say, what did you do first? As if they could peer into my soul to see if I've been reformed or ruined. So I might as well address that today. Yes, I went to law school first. I now realize I went to law school for my parents. They told me I was going to be the first family lawyer. And I said, yes, I'm going to do it. And I got there and I was thinking, oh boy, what did I do? It really wasn't something I realized I was really interested in. I was interested in using the legal tools as a way to inspire justice, as a way to inspire social justice. And that can happen. But I found and thought that there was an understanding of this disconnect between the theory of the law and the imposition of the law. So how is it that we get the law and this country in some respects to live up to its greatest aspirations? And in some respects, that's what we're going to talk about today. How do we get health care systems, providers and executives to live up to the greatest aspirations of a notion of health in this country? And I can tell you, and we'll talk about this, the quandary of the pampered executive is something that we have to think about more deeply. And I'm one of them. I'll tell you. The executive mindset is an interesting and unique one, and one that will have to unpack if we're going to be successful in thinking about ethics more broadly. So with that as an opening of sorts, here's what we're going to talk about today. We're going to talk about this notion of social justice. There's obviously different concepts of social justice. We're going to talk about these changing health care landscape. I do believe the floor is kind of moving beneath our feet in ways we don't fully understand. And I believe the one thing that I can do for you today is pull back the corporate veil and give you an inside look at the decision making and the mindset and what's happening in these large mega health systems. The third one is this value in population health. Notice there's no S on the end of that, right? And we're not talking values. We're talking the value, and it has a distinct definition. And what does that mean for us in health care? And lastly, I think we're going to talk about these two notions of aligning social justice with this notion of FIFA value as you move from FIFA service to FIFA value, and then we're going to close with a conversation on building an ethics infrastructure. And I do believe that includes ethics committees, but it's much broader. How do we influence C-suite decisions? How do we think about our relationship with societies in a different manner? So with that as a backdrop, let's get started. A little bit more about what I do at Centura. I've been at Centura for two years now. Colorado's an interesting place. Still trying to figure it out. Not really a big hiker or a camper. Working on it. So here are the areas that I provide oversight to at Centura Health. Community health, behavioral health, so I can substance abuse, our mission and values. And I am the mission leader for the organization. My title's Chains and Values, which is a line, but I am the mission leader, and I'm happy to see that Theo, who's going to be on the stage later, is also considered a mission leader, particularly in a non-faith-based setting, because oftentimes that notion of mission leader is connected to faith-based. And I always say that we can tell if we're doing the work of mission well, if non-faith-based and secular institutions say, you know it, I need that rule. And that's our mindset. So mission and values is an area. Research operations. We actually have 270 open trials across our 18 hospitals in our two states, and we're taking our five IRBs and making them one. Not fun, but we need to get there for better protection for the patients. Spiritual care is under my domain as well, as well as ethics, obviously, and I've been fortunate enough to lead our global health programs. Centura Health has global health in Nepal, Rwanda, Tanzania, Haiti, and Peru. And we'll talk a little bit about that today and why it is that health systems do that. We always start the mission. The mission at Centura Health is extending the healing ministry of Christ by caring for those who are ill and by nurturing the health of the people in our communities. And I think that it has both theological and social importance, particularly that last line that talks about nurturing the health of the people in our communities. How can you do that if you don't address some of these social issues that are part and parcel of health care? And when you think of social justice, let's begin, the definition I chose to use or the location I chose to locate this notion of social justice was in public health. And Lawrence Gostin and many other public health issues would argue that the historic dream of public health is the dream of social justice. And if you're talking about what's core to the mission and core to the organizations, and if we think about health care as part of the public health infrastructure, then this is a great way to locate public health and its understanding of the importance of public health and social determinants in improving health care outcomes. Now, it'd be easy enough to talk about many different concepts of justice and to spend a lot of time on that. That's not my goal today. My goal today is really to get into the weeds a little bit, talk a little about theory and then get into practice in ways in which inform future ethical inquiries. John Rawls, he speaks to this notion of justice in a different manner, but he does talk about what's just and unjust as being the way that institutions deal with these facts. And if you think about the institution of health care and the institution of health systems, many of them are non-profit and there's a calling for them to live up to that non-profit status. We're going to unpack that today. I think it's important to talk about a theological concept of social justice as well. 15% roughly of the hospitals in this country are faith-based. On the Catholic side, one in six patients in this country are seen in Catholic health care. So to unpack that requires us to understand some of the background in Catholic health care where there is a biblical mandate under this ethical and religious directives. Those are the normative guidelines for Catholic health care. There's a mandate to care for the poor and to express concrete action at all levels of Catholic health care. So it requires in some respects to focus on these issues of the institution, the adequacy of care for the poor. You can read in that care for the poor a notion of the preferential option for the poor. Now imagine if we were fully lived up to that. The preferential option for the poor argues that you should put the rights of the poor for your very own rights. Imagine what society would look like if we really did that. So in this respect, there's an ethical and religious directive mandate in Catholic health care to focus on social issues and I say social justice as well. You can also look at individual mission statements. I took a shot at looking at the mission statements of the folks who will be speaking after me today and you know you some areas of connection better than others. The one that I bolded there is Boston Medical Center where it says we will provide consistently excellent and accessible health services to all in need of care regardless of status or ability to pay. Exceptional care without exception. You could read into that notions of access, notions of willingness to exceed anyone irrespective of the ability to pay. I think there's some social justice themes in the mission and values of all our organizations that we can lift up as a burning platform of sorts to inspire action to think about ethics differently. I also want to highlight the question of mission and I see Jim Saban in the audience you know he made this book years ago along with others No Marge and No Mission and I know that Jim did not mean for this to occur and we talked a little about it yesterday but that book and that method has been used and continues to be used by CFOs to say you know what sorry we got to make this tough decision it might not be fully in line with who we want to be but no margin no mission right that's not what Jim intended obviously shaking it vigorously I can tell you I've heard that conversation over and over again and that quote over and over again and I can say that what I would like to think about is our mission our margin is our mission and that if you think about the mission differently it is then that mission that allows you to achieve your margin what do I mean by that there's real you know whiz kids now in the background who are studying this very closely and they're showing a percentage point increase in patient satisfaction and what that means to the bottom line of hospitals and there's an argument there that if we can make our employees feel more satisfied that connection in impact happens to the patients so happier employees in a more just environment means happier patients which leads to increased margin that's the way I want to look at it I want to connect and align our financial objectives with our mission-based objectives and not see the two as different but see them as interwoven not in ways that one outweigh the other now we're going to talk about this changing concept of health care I want to spend some significant time on this because I think that we don't fully understand what's happening in our communities and I call it we're in the age of what I call the mega health system where we have these large multi-state international in some respects health systems and the question is what does that mean there's some great benefits to this obviously right efficiencies cost savings but at the same time what does that mean when you have these large systems with resources spread out from different hospitals and then some of those resources can be consolidated at a system level and I want to highlight 10 largest health systems in the country five six of those pardon located in blue are actually non-profit health systems so I know we spent a lot of time kind of understanding the challenge of for-profit health care but I want to highlight this kind of consolidation and the large systems are both for-profit and non-profit alike hospital corporation of america number two on the list they actually have five hospitals in england including princess grace hospital and london bridge hospital now do the folks in england know that decisions made based in headquarters in nashville are affecting their folks there what does that mean and if you think about it you can connect it a little bit to like the bank we all remember that local bank I'm going to date myself I opened my passport account years ago and I was so excited that was my bank and my passport account but in the era of this consolidation and these mega banks we now have these you know corporate conglomerates that have banks in different communities does that bank still have that particular focus on that community that it used to have that's a question similarly does these community hospitals that are in these large networks have that same focus on that particular community could be but I think there's things there for us to study and explore one potential area of insight is related to this question of what happens in the era of medicaid expansion when charity care numbers continue to decline 5.7 billion dollars in 2015 obviously connected a lot to medicaid expansion and my question is what happens to those dollars now I am an executive so I'm not naive enough to say you know it's a direct line between the dollar savings and what should be pushed back in the community but I think increased transparency in this space is going to be an important issue it's a clear ethical issue if communities are not paying taxes in that local community and resources that could be pushed back in that community are taken elsewhere it's a challenge and it's something we need to get behind and I have a way for us to think about it and look about it but another challenge in the same vein is as you take on multiple hospitals and you know we're generally in integrated health systems so physician practices and other areas the move from a holding company where you kind of just buy it and hold and I think the majority of systems are still there holding and not fully operating as a system yet but the move to a operating company requires you to align systems and that is not an easy thing to do it's a circuitous path between the holding company and an operating company I can tell you just one example if you look at these multiple systems even in this year state you can see that multiple hospitals in the same system are applying for the same federal grant and they're not aligning with the same researcher or the same grant writer they're all going competitively against each other how does that make sense as a system how does that make sense for us subsidizing that with our taxpayer dollars so again the move to operating company is a challenge it takes some times it it means you move from competing against each other how many systems do we know of who say we are the best in this and you say oh you're the best where and you're in four different locations claiming you're the best right how does that even make sense so we have some challenges but opportunities as well this turnover that is occurring in healthcare 18 percent by CEOs in 2014 and 2015 is the highest turnover rate at the top in any profession in the country and it's led by this industry consolidation that we just talked about but it's also this new challenge for healthcare CEOs it's one thing in the fee-for-service world to cozy up to the docks and make sure you get a certain number of cases you know what you're going to get in revenue by a number of cases it's a total different thing to say okay now we're in this budget-based fee-for-service care on the other side and how is it that i model both continuing foot up foot on the pedal as we call it on the fee-for-service but at the same time get ready for preventive health care get ready for this value-based model we have a budget-based care quality metrics it's a challenge but it's also an opportunity for us so when you think of what we should be thinking about to build an ethics infrastructure we've got a tremendous opportunity with new leaders coming in to shape them to groom them and to be a source of new leaders moving into this space and they want to speak specifically to millennials in the world what we need are people who are thinking about things beyond themselves and i believe that communitarian i want to do something bigger than myself in part and parcel of the millennial culture so i think we have a tremendous opportunity to leverage that and bring the right leadership into health care and these changing times at this point i'm going to talk a little about this question of value and unpack it a little bit more and i think whenever we talk about a co's and value i think you know there's always different levels of understanding so i want to unpack it so i think of this as a step ladder of sorts right and i put the slide together so when the fragmented fee-for-serve is dominated world currently but that step ladder of sorts all the way up to the a co full risk in the corner is one that we are on a journey of right now every hospital in this country has some kind of bundle payment now some of them don't know but that's made the requirement you're in bundle payments and this notion of bundle payment means that instead of just worrying about your individual procedure and passing them off on to the next party you get a fee-for-service platform but you get this bundle payment model it means that if you're going to do a procedure to someone you better worry about where you're going to get them discharged to you better worry about are they going to go to the rehab and there's ways in which that them not being supported along the care continuum by you will impact your bottom line requires a different way of thinking it requires an opportunity to think outside the hospital walls and to think about social structures and social issues as part and parcel of the care model all the way up to the top the a co full risk that's where the rubber meets the road are you willing as an organization to go to a budget-based model and say that if I keep under a certain budget I collect that revenue and I get to share in the savings or if I don't keep you under a certain budget I'm going to lose on that individual's care so I want to highlight that so if you have a budget for ten thousand dollars an individual was able to have only eight thousand dollars of cost of care that year is a two thousand dollar benefit there if you have full risk all the way up and if let's say that same ten thousand dollars was a budget but the person spent fifteen thousand care you could lose five thousand dollars on that one individual's care and if you quantify that by the millions of patients mega health system see you could see the big risk and reward but herein lies the opportunity for us as ethicists to think about how this new payment model and CMS and HHS are clear on this they're hoping to have 75 percent of all of their models in some kind of value-based arrangement by 2018 not too far away it's a tremendous opportunity for us to think more differently about what we can do from an ethic standpoint with these new incentive models key takeaway here is grandma grandma you might ask what does that do with anything well grandma's always have something to do with everything but I think the issue is with does grandma need that elective surgery that knee surgery for instance right and sometimes and physicians get real upset when I say this but I've seen it in practice sometimes it could be tied to the way physicians are paid I hope that's not our shattering right so for instance if you're in a free-for-service model there's a way in which you can communicate subliminally or otherwise and grandma you want that surgery you need that procedure but I can tell you I've been in rooms and it's not always a good situation when they look at the contract first and say are you in the fee-for-service world or are you in this value-based world we have to keep you under a certain budget they say oh well grandma the evidence on this knee surgery is not that clear and here's the challenge grandma doesn't know the hidden incentives grandma doesn't know if you're paid for volume or if you're paid to keep somebody in a budget I don't think it's just and I don't think it's a full notion of transparency until we hit that notion and fully understand how peaks are being how individuals are being paid and we can crack that nut for our communities so they can be on guard for some reason lawyers don't have this problem right when you go to a lawyer the most trusted times I could say that is somebody with a law degree so you get a second opinion maybe a third opinion but it's that heightened respect of physicians that's a good thing that also I think is a challenge for a active consumer of health care products and it's something we have to get behind so when you think about what this means for the future of health care this question of the ACO population still a lot smaller under these bundle payments is value population than the general population but if you're going to do well in the new ACO model the general population is going to be what's going to put move essentially into these risk contracts under the ACO population so the takeaway is it makes sense for us to start thinking about social justice issues and social structures as part of the care model a healthier community is one we're more likely to take risk on I think we can do well in the budget-based arena so this is coming and it's a perfect time for us to align I want to align our visions of what an ethical health system can look like with the payment model in order to do that you need a nuanced understanding of this payment model I was fortunate enough last week to do a keynote at the medical legal partnership in Indianapolis and they're doing really really well that group is growing and thriving and one of the first questions is when do you think health systems are going to get it James and you can hear in that this deep pain and tired of dealing with the same old lack of understanding of incentives and a misaligned system but I argued back that the time is now we are in the arena now where those on the outside and inside can help reshape the system and it's tied to a deep understanding of where the system is so in the past we have this and we still do right have this broken kind of separate structured system where medical care and behavioral health are split social services and public health are generally in different departments but obviously in this new model of care if you want to think about how you can reduce the cost of care by leveraging social resources you want to meld behavioral health and medical care you want to make sure that the public health and social service agencies are working closely together in some respect that has happened already and started to happen I can give you an example we are doing our own Medicaid applications across the state of Colorado so when the state does it they usually process those applications in 90 days or never think of the department of motor vehicles when we do it we process it in zero to three days right and we know that that application processing and preventing that churning is crucial to supporting the care of our most vulnerable patients it's an opportunity for us to think about social services differently at the same time CMS has approved seven of these what they call disparate programs and these programs are intentional about marrying the cost of social services and medical care and figuring out how to reduce the total cost of cares in ways in ways that defy traditional notions of health care and here's one of the one of the greatest opportunities I believe for us in this new model of care and think when you in the past in the fee-for-service world that we're still dominated by it's clear individuals come into the hospital hey all we know is what we know we provide you your procedure you depart in the new arena it's a potential opportunity for you to look at disparities differently if you can say have to keep somebody under a certain budget maybe I better understand the cultural mores maybe I understand that certain cultures have higher dietary patterns or other areas that would move their health care costs it's a tremendous opportunity for us to align our model of thinking when I say our model a model that's hopefully informed by a certain notion of epic and responsibility to each other with a business model the time can this cannot be underestimated I think that the whenever I talk about moral arguments I try to get in the pulpit and talk about that in executive tables it doesn't go over well I don't get far but as soon as I start talking about the financial imperatives and I change and I get a little bit chameleon like I talk as if I'm a CFO and then I align it to our mission I win I win every time so the key message is learn the inner workings of health system delivery finance it's not the most interesting it's not hard everybody in this room can do it and the CFOs of the world and the finance folks always have a certain bravado like yes we understand this and the rest of the world doesn't not hard we can understand it and in fact we have to if we're going to move the dial on some of these issues in the future so when you think about a community health improvement plan and things that are addressed in that area this state is fortunate you have a lot of regulation in this regard this was what I believe to be a best practice it is the state's model needs assessment community health improvement plan and annual community benefit report but I can tell you there's many states where there's no regulations on this at all including Colorado not the most regulated state and in those areas it's really just that floor requirement a three-year needs assessment and a three-year community health improvement plan of sorts but as a start I have to say shame on us shame on us as a health system is to be required to do needs assessment for every three years if you recall non-profit health systems get this tax subsidy to relieve the burden the public burden of of the government and to do that is to live up to that tax profit that nonprofit status and they don't always do that so I want to highlight this a little bit because I think what I'm trying to show you is a new way to think about one area of ethics that maybe we haven't had enough data to look into closely this question of community benefit so where's one hospital that we have in Pueblo Pueblo is in Colorado it's a mining town in the southern part of the state and I'll pause for a moment for a brief story and I think stories are important I had a professor Stanley Harwas and he claimed that we are a story-formed community I got a little thumbs up for Stanley thank you because he always gives you a hard time what daily though but I think that part of it is that so this story stories form us and they perform us unbeknownst and we remember stories you might not remember a lot of the slides but you'll remember the stories so here's one so I was in Pueblo and I was doing this work doing our needs assessment and we were doing our qualitative interviews and again I'm from the east coast so I'm used to Hispanics who speak Spanish right so down there it's very not it's very you know common but it's also very common to not speak Spanish so I was pretty naive I went there and I started talking and I said wow you don't speak Spanish how is that I said well you don't speak Swahili I was like oh I get it so I say that story to highlight that even if you think you haven't figured out from a notion of cultural competence you can make mistakes so in this community I think it's important to highlight that what I did was look at the service area where this hospital is and I looked at some of their social their issues in the community and then I marry that to Colorado to see if there is a higher incidence in these areas so the key here is that yes there is this is a food desert so folks are not eating healthy fruits it's not the safest place so there's not a lot of physical activity and there's high smoking and the reason I'm highlighting this on this level is because I think it's a way for us to think about ethics and community benefit what are we what's the needs in our community what's the state average and what are we doing about it now in the past there wasn't a lot of transparency in this area there wasn't a lot of ways for ethicists to look at this data today there is the IRS requires now a schedule h form 990 and here are some of the questions they ask one if a hospital addressed the needs identified and it's most recently connected to now how did they do it one do they include community benefit section in the operational plan I think that's a great question is it meaningful or is it just a joke on the side two did you budget for it so there's two questions they have to answer let's go to question seven did the hospital facility address all the needs identified as most recently conducted chenna community health needs assessment but question 11 is fascinating because it says describe how the facility addressed those needs and if the facility did not address those needs explain the reasons why not so let's take a step back on the previous slide tell me how it is that if we have these areas higher than state incidents in our community that we do not address that issue so I think I'm hoping to highlight here for you a way in which to analyze from an ethical standpoint community benefits look at the needs in those communities look at the most prevalent needs in that same community and at the same time decide if the needs are connected to the behaviors and if not and if higher than state average issue why not they really don't have an answer to say why are not addressing an issue if you get a tax status in that or tax deduction in that community to do so so it's a way for us to think about ethics from a community benefit standpoint but to transition now and keep the ethics theme but focusing specifically on this move and thinking about what we can do in social justice and the FIFA value arena so again I'm very fortunate Colorado is such an interesting place so independent love to do things outside the box I think many of you know that it has both legalized marijuana and at the same time strong gun control right that's a odd mix and I think it highlights the state what we're dealing with there a quick side by side bar story all the colleges there have a 40% increase in their application rate for colleges folks know I okay so when the new rankings come out there should be an asterisk that's why they have these higher rankings but what we've done at Centura and it's a way to think about this is we've taken down our traditional quality committee we don't have a traditional quality committee anymore and I think for folks in the room many of you know that's kind of like the the rail right you don't touch that how could you do such a thing we now call it our community health value committee we marry both our community needs and our community concerns with our traditional quality metrics and we think it takes us down the path of focusing on both the community needs and a more myopic kind of medical care needs but the way that we look at it is through this about a 300 page iom report there's also a four page cliff note but we're able to put all our thinking into this framework and from the community side if you look at engage people engage communities at the bottom it allows me to think more formally and thoughtfully about how this nebulous notion of community engagement can be supported at the same time we know i mean this is this is not new the question of social determinants of health becomes more and more important and this highlights this here questions of employment education how does that move the dial and what's the role for us as health system and its ethicists now this is that this is interesting but you know there's a lot of people still who would argue that it has nothing to do with social factors has nothing to do with social determinants but it's all about individual responsibility and i have those conversations at the most senior level of the organization to this day so we have some homework to do and even if folks aren't going to understand a basic truth there's ways in which again for us to align the financial incentives with what we know to be true in ways that move the dial for our patients care this slide scares folks so i pull this slide out in a uh executive meeting and i i'm on the left of that red are things that health care systems are used to addressing so we're used to addressing things of quality of care clinical status access to care but on the right are things that we need to get better at in order to thrive in this new model of care but look how scary it gets to some and i can tell you they were pretty scared when i brought this up when you start thinking about issues of care seeking approaches public transportation safety security you know i have to see if folks say hey time out time out how are we supposed to address all that why would we address that and i'm arguing that the same way we have clinical pathways you know if somebody comes into a hospital you know if you're based on the test or the outcome to send them to cardiology or oncology we need a similar community-based pathway so if someone has an issue associated with diabetes and if they live in a certain community well how are we having a pathway for them are we building farmers markets and i again say that it's part and parcel of this new health care model and it's a tremendous opportunity for us as ethicists to think about from a programmatic level what can we support the hospitals in doing in ways that are aligned with their bottom line ultimately we're talking about this move from a biomedical model of care to a sociocultural model of care it takes us away from thinking only about the disease burden into a broader notion of health and with this broader notion of health whole person care is a perfect example it allows us to think about the individual not as a medical condition alone but from issues of faith to their desires it brings it to the table more prominently we're not there yet but we're moving down that direction and now i'm going to talk about this question of the ethics infrastructure so obviously ethics committees are important to moving to the inquiries that we that we see but i want to argue today that the ethics committee role has to change as health care is changing and the error of a mega health system what is the role of ethics committees you have a local ethics committees but you also have these system ethics committees increasingly charged with looking at joint ventures for instance what does it mean for a non-profit institute to partner with a joint venture with a for-profit private equity company how do ethics committees play a role in that analysis so what i say is that we need an ethics infrastructure and there's no magic to how we we think about this or locate it but the real issues are thinking about this ethics committee as one arrow in the equivalent of sorts one area where you can think of supporting the organization in this journey towards a more ethical organization so the ethics committee is one area but more broadly than the ethics committee what about the management staff meetings an interesting study an interesting thing to do would be to get a list of all the committee councils and management meetings in health care there are a ton we did it for our system there is over a hundred regular meetings okay and you look at those meetings and you think of okay in addition to the ethics committee how do we have champions how do we play a role in these management and staff meetings and ways that allow us to make the organization focus on things that we cannot really achieve in the ethics committee alone that's the key the ethics committee is important but an ethics committee alone will not make an ethics will not make it an ethical organization in some respects you should think about it as how do you design ethical health systems how do you do that at a time of consolidation what are all the different elements of a health system what are all the ways in which we should be thinking about ethical increase in this new system so when you think of number two on this list is systems and processes i just put a couple of examples here is there a values based decision making process in place at the highest level of the organization we have what's called a value impact analysis where every decision is made we do the normal market share data and the normal analysis but then we do a real deep dive into our values our values are our compassion respect integrity stewardship excellence and imagination so we'll look at each of those values and to see is there value integrity are we doing this just for the financials or are we actually thinking about it in ways that are more profound and meaningful the area of low wage earner subsidies is something we're able to get through in my organization and many others where you look at some of the low wage earners and you subsidize some of their health care and other costs as a way to make sure that the organization one can keep those valuable employees in place but two can ensure that we are thinking about our organization with a little bit more of a lens towards those most vulnerable populations and then I think where the rubber meets the road is leadership and I often struggle with this because I think that we give too much credence to leadership alone if not the leaders alone that drive the organization I believe that the organization itself and the community members have much more latent power than they realize to leverage and use to drive the organization but it's pretty clear you have to be in the room when these decisions are made and if you're not in the room and if the ethics committees are not going to be reporting regularly to the leadership then you'll need someone at the table and I'm fortunate enough to be at that table but I also recognize it's rare you don't have ethics executives in that in the room where it happens and I use that quote the room where it happens it's a it's a song from the Hamilton play and I think it's fascinating because he highlights his question on being in the room where it happened it was a small group of folks that were making decisions it's the same thing I mean every day we meet once every two months for eight hours and we make rapid fire decisions about things that impact lots of people's lives I mean we saw earlier in the slide we have these health systems some of them have 100,000 employees 100,000 a decision they make about benefits and others are made rapid fire in ways that affect the lives of multiple people and let's not to forget the millions of patients behind the scenes as well so we're going to have to crack that nut it's not that easy the pampered executives in this room I'm one and in that room I'll give you some stories to highlight what you're dealing with here and I find it troubling I find it troubling particularly in the nonprofit arena where all our taxpayers money pay for this behavior so one of my first jobs in health care I was young and naive and I was thinking hey we're here to to improve this community's health so I started working with a fellow executive we were peers and I had a plan and I was going to present to the team and I was excited about it and he said well I don't think this plan works that great how much you take this plan and this new plan is one where you'll have this new competitive environment within our organization and we'll go against each other on certain areas and I was thinking this doesn't make sense and he said but no it'll thrive it'll work so I'm thinking okay you've been here longer than me win it together let's do it go to the room I make this claim I stated first comment was from the person who told me to put this together and he said that's a horrific idea he said that is not going to work it will lead to the things I had said it wouldn't work he said it'll lead to dissension why we do that and I just remember thinking wow and I couldn't just say well well that's not what you said earlier you know it doesn't work in those formats right there's a certain protocol so I swallowed it and I remember that night having this pain on my neck that I hadn't felt before or afterwards and I learned a valuable lesson there there's um we are not as aligned as we appear in these executive wings and there's a lot of hidden incentives for us individually that take us away from the greater good of our communities and our societies and our fellow executives and I think it's something that we really have to get behind in order to move the dial so again with 18 turnover and health care is a tremendous opportunity for us to focus on this at the same time we know there's between depending on the organization 70 to 80 percent women usually that's not usually reflected in leadership so it's a tremendous opportunity for us to do that and the same time we know at the same time with 31 percent of our patients across the country being persons of color we recognize that there's not 31 percent leadership not at the board level not at the governance level not at the executive level so a tremendous opportunity for us to think about that differently as well we do have some guidance however right we do have the american college of health care executives this code of ethics and this does make sense I think to read completely the fundamental objectives of the health care management profession are to maintain or enhance the overall dignity quality and well-being of every individual needing health care services and to create a more equitable accessible effective and efficient health system so the challenge is there the mantra is there the question is how do we live up to this I started this presentation by talking about why I got into the law I wanted us the law I wanted to use the law and connect that to the Judeo-Christian basis of the law that's why I went to divinity school I said there's a Judeo-Christian basis underpinning this law and somehow I want to explore that more and I want to figure out how it is that we connect those two themes more meaningfully and I think that the same thing holds true we need to force health care executives and systems to live up to their greatest aspirations and I think that my key messages at the time is now because the financial system aligns we're not there yet but while this is being designed let's go about the business of together designing an ethical health system so with that get to the favorite part of my presentation where I get to listen to you ask questions and comments thanks for your time today