ETHICS AUDIT

• Evaluate where organization may be falling below its own

standards and expectations.
• Comprehensive review of policies, procedures and perceptions to
determine consistency with organization’s mission, vision and values.
• Identify real and perceived problems.
SYMPTOMS SUGGESTING THE NEED FOR AN
AUDIT
• Decline in patient, employee or physician satisfaction ratings
• Higher turn over rates
• Reduction in community support as evidenced by the number and size of
donations, number of volunteers and average weekly hours, and attendance
at sponsored programs/events
• Allegations of conflicts of interest
• Increase in litigation against the institution
AHA ORGANIZATIONAL ETHICS INITIATIVE
Part one:
Existing organizational materials and raised questions about written
statements of ethical principles, codes of conduct and pertinent
policies and procedures
EXAMPLE
What procedures help assure
compliance with ethical
requirements?
AHA ORGANIZATIONAL ETHICS INITIATIVE

Part two:
Training, publications, and formal process
EXAMPLE
What would an employee be
expected to do if he or she became
aware of unethical activity and what
steps would the organization take in
responding to the report?
AHA ORGANIZATIONAL ETHICS INITIATIVE

Part three:
Organizational structure
EXAMPLE

If an ethics committee exists, what is its

role in organizational ethics?
AHA ORGANIZATIONAL ETHICS INITIATIVE

Part four:
Organizational character
EXAMPLE

What are the institution’s ethical

obligations to its community?
AHA ORGANIZATIONAL ETHICS INITIATIVE
Part five:
Most significant ethical challenges facing the
organization
AHA ORGANIZATIONAL ETHICS INITIATIVE
Part six:
Assess the organization’s ethics standards
and practices
CONDUCTING AN ETHICS AUDIT AND BENEFITING
FROM ITS RESULTS COMPONENTS
• Preparing a communication strategy to inform the organization and its
stakeholders of the audit
• Collecting and analyzing appropriate documents
• Reviewing roles and responsibilities of key staff members and relevant
committees
• Preparing interview and survey documents
• Performing interviews and conducting surveys
• Determining where there are contradictions and inconsistencies
• Compiling and disseminating the results
PLANS TO ADDRESS PROBLEMS
•Redesigning interview and employment procedures
•Redesigning orientation and in-service education programs
•Establishing new policies, positions or committees
•Revising existing position descriptions or committee
responsibilities
•Creating casebook on ethical dilemmas for use in supervisory
training to assist them in recognizing and reconciling competing
values
PLANS TO ADDRESS PROBLEMS
•Implementing a telephone hotline to report questionable
conduct
•Expanding the role of institution’s ethics committee to cover
issues relating to both organizational and clinical ethics
•Re-emphasizing compliance with the organization’s code of
conduct during performance reviews