Cambridge Quarterly of Healthcare Ethics (2017), 26 , 173179 . Cambridge University Press 2016.doi:10.1017/S0963180116000748 173PerspectivesPrinciples of Ethical Leadership Illustratedby Institutional Management of PrionContamination of Neurosurgical InstrumentsTIM LAHEY , JOSEPH PEPE , and WILLIAM NELSONIntroductionIn the Introduction to Managerial Ethics inHealthcare, 1 the editors argue the mostimportant responsibility of a healthcareleader is to protect a hospitals ethicalcore values despite challenges. The JointCommission, responsible for accreditinghealthcare organizations, likewisedirects the leadership of institutions tocarry out their patient care and businessarrangements in an ethical manner. 2The ethical principles that are foundationalto organizational values and theleadership of hospitals include respectfor patient autonomy, prioritizing patientinterests, and the delivery of care in ajust and equitable manner. The Instituteof Medicines six aims for healthcaredeliveryquality, effective, patientcentered,effi cient, safe, and timelyalign perfectly with these fundamentalethical principles. 3 Taken together, thesevalues should drive hospital decisionsin a concrete fashion.This point is unambiguous: ethicsgroundedvalues are the core of todayshealthcare organizations, and the successof a hospital and its leadership ismeasured by the alignment of theirdecisions and actions with those values.This is true every day; however, it isduring signifi cant challenges and timesof uncertainty that the true measure ofa hospitals ethical character is testedand displayed. 4In this article, we detail how theleader of Catholic Medical Center inManchester, New Hampshire confronteda challenge that would test his moralcompass of the leadership and overallcharacter of the hospital: news thatneurosurgical instruments used in thecare of multiple patients may have beencontaminated with a lethal transmissibleinfection. In so doing, this leader revealedkey principles of ethical leadership ofhealthcare organizations.We begin with a report of the originalcase before delineating next steps in thehospital investigation and communicationsresponse. In so doing, we discussways in which the leadership of CatholicMedical Center exemplifi ed ethical leadershipin a time of great challenge.Brief Case ReportIn May 2013, a 70-year-old male presentedto Catholic Medical Center inManchester, New Hampshire, withsevere vertigo and diffi culty walking.Routine blood work, computed tomographyof the brain, and consultation byneurologists and psychiatrists showedno explanation for the symptoms, whichworsened despite physical rehabilitation.Magnetic resonance imaging (MRI)revealed a brain cyst and signs of elevatedintracranial pressure, but lumbarpuncture and spinal fl uid analysis didnot improve symptoms or reveal additionaldiagnoses. Given the diagnosticuncertainty, and concern that the brainlesion was contributing to elevated intracranialpressure, the patient underwentneurosurgical decompression of the cyst.Perspectives174During the postoperative period, thepatient developed myoclonus, whichwas originally attributed to an undefi nedmetabolic derangement. Eventually thepatient was discharged to a rehabilitationcenter for postoperative recovery.Weeks later, the patient was brought tothe emergency department with rapidlydeteriorating neurological symptoms,including progressive cognitive impairment.Repeat MRI showed abnormalitieson both sides of the brain regionsknown as the caudate and the putamen.These fi ndings were interpreted as suggestiveof a long list of diagnostic possibilitiesincluding CreutzfeldtJakobdisease (CJD), a rare transmission priondisease, for which a consulting neurologistfelt the patients symptoms wereatypical.Physicians admitted the patient toCatholic Medical Center for additionalevaluation including electroencephalography,additional brain imaging,and spinal fl uid analysis, including forthe presence of two proteins found inpatients with CJD, 14-3-3 protein, andthe tau protein. Within days, the hospitalreceived word that cerebrospinalfl uid testing showed positive tau proteinand 14-3-3 protein. The NationalPrion Center, which by policy contactedthe laboratory director and head ofinfection control of Catholic MedicalCenter, indicated that these fi ndingswere highly suggestive of the diagnosisof CJD.Leadership ResponseThe same day in mid-August that thelaboratory was notifi ed of the positive14-3-3 and tau protein results, the executiveleadership team at CatholicMedical Center alerted the neurosurgeonsinvolved in the case. Because theprion agent of CJD can contaminateneurosurgical instruments in a fashionnot removed by standard sanitationmeasures, all neurosurgical instrumentsused in the patients brain surgery werequarantined and all neurosurgery atCatholic Medical Center was haltedtemporarily.Multiple internal communicationsensued, including e-mails, meetings,and phone calls among the CEO, hospitalleadership, risk management, infectioncontrol, legal department, andquality department about the potentialexposure of other patients who had hadneurosurgery procedures following theindex patients procedure. Early on, thehospital CEO directly contacted theNew Hampshire Department of Healthand Human Services (NH DHHS) topromise that the ensuing collaborationbetween the hospital and the statewould be a model for others to follow.During these contacts, the hospitalsCEO clarifi ed that patient safety was thehighest priority, above fi nancial, legal,and personal considerations. NH DHHSpromised full support for CatholicMedical Center, and initiated an epidemiologicalinvestigation.Close to this time, the patient died,and, therefore, state offi cials obtainedpermission from his family to conducta brain autopsy. Initially, pathologistsat Catholic Medical Center proposedto take a week to conduct the autopsy.Concerned that this timeline did notalign with the urgency of the situation,the CEO contacted the executive teamto emphasize the seriousness of the situationand to urge a more rapid action.The autopsy was fi nally completed inin mid-September.Prior to knowing the autopsy results,the CEO convened an incident managementteam days after the cerebrospinalfl uid results were made known. In theirinaugural meeting, the CEO remindedthe incident management team thatalthough potential contamination ofneurosurgical instruments could not bechanged, the hospital was in control ofPerspectives175its reaction to the situation. He calledfor leadership, attention, teamwork, andfull engagement. He delegated responsibilitiesto individuals based on talenteven when higher-ranked individualsmight have been the default choice. Forexample, instead of appointing a hierarchicallydefault appointee, a vice president,the CEO appointed the complianceoffi cer as the incident commander. Shewas charged with collecting, processing,and supervising information aboutthe incident action plan because ofher known attention to detail, sense ofurgency, history of close follow-up, andteam approach to solutions.The CEOs incident managementteam reviewed related hospital policies,and instigated a root cause analysis.Alert fl ags were placed in the electronicmedical records of patients on whomthe potentially contaminated neurosurgicalinstruments had been used, in theunlikely event that any of them presentedwith the need for invasive treatment,and notifi cation was made toanother hospital in the same city, whichrented the instruments, to do the same.The incident management team partneredwith experts in sterilization standardsand other prion-related issues,including a consultant at the NationalInstitutes of Health. Hospital risk managementwas involved in the investigation;however, the CEO promised to allinvolved that the institutions fi rst prioritywas the expeditious and thoroughprotection of patient interests. He specified that the potential legal ramifi cationsof the contaminated neurosurgicalinstruments would not preclude theinstitution from doing the right thingfor patients, their families, and thecommunity.At this time, the CEO and hospitalleadership decided to tell exposedpatients and the community immediatelyon confi rmation of the diagnosisat autopsy. Soon thereafter, the hospitallearned that the results of confi rmatorytesting during autopsy would take severalweeks to return from the NationalPrion Laboratory. The CEO felt this wasan unacceptable delay, and decidedto notify potentially exposed patientsand the community immediately ratherthan wait for a defi nitive index casediagnosis.This decision was controversial. Somemembers of the hospitals leadershipteam and outside consultants werehesitant to inform potentially exposedpatients out of concern for infl ictingunnecessary worry on notifi ed patients,and also because the risk of contractingCJD from contaminated neurosurgicalinstruments is extremely low. (Therehave been only four cases reported ofCJD transmission from contaminatedneurosurgical instruments.) 5 This concernwas heightened by the fact thatCJD is invariably lethal, and there isno test available to determine whethera potentially exposed patient has trulybeen exposed or if that patient willdevelop the disease even years later.There were conversations among seniorhospital management about legal exposure,bad publicity, and even potentialloss of jobs, including that of the CEO.The CEO dismissed those concerns asirrelevant to what patient safety andinstitutional trust required.The CEO emphasized that the institutionhad an obligation to be truthful,and that anxiety among potentiallyexposed patients could be mitigated byensuring that notifi cation was respectful,compassionate, and accompanied bysolid education and ongoing counseling.The CEO felt strongly that potentiallyexposed patients needed to knowwhat had happened so that they couldmake informed choices about organdonation, participate in CJD-relatedclinical studies, make end-of-life planningdecisions or, in most cases, donothing. He also wanted to ensure thatPerspectives176those potentially exposed neurosurgicalpatients did not unwittingly risk furthertransmission by undergoing additionalneurosurgery in another institutionwhere their potential exposure wasunknown. The CEO also wanted to protectpatient and community trust in thehospital by showing that it would actin a trustworthy manner. To ensure theinstitution took the right path, thehospital CEO consulted ethicists whosupported his decision to disclose thepotential exposure to affected patients.Close to the same time, the hospitalconsidered if it should destroy two setsof potentially contaminated neurosurgicalinstruments, as it was not knownwhich was used in the original case.This decision was complicated by conflicting and often unclear recommendationsfrom the Centers for DiseaseControl (CDC) and several consultants.6 , 7 , 8 , 9 Given this uncertainty, andthe desire to protect future neurosurgicalpatients, the instruments (costingmore than $200,000) were permanentlyquarantined for later destruction.Two weeks after Catholic MedicalCenter learned of the CJD diagnosis,representatives of the hospital notifi edprimary care physicians of the potentiallyexposed patients, and educatedthem about the risk to patients andmeasures that the hospital was takingto ameliorate it. The hospital providedreference materials to help primarycare physicians give informed and consistentadvice to patients.The chief medical offi cer of CatholicMedical Center and a patient navigatormet with all eight patients (or theirlegal representatives) individually. Thepatient navigator was chosen based ona reputation for being a compassionateand nuanced communicator. In additionto reviewing the facts of the situation in acompassionate and respectful manner,and apologizing for the potential exposure,hospital representatives providedpatients with written information plusdirections to additional informationalresources. Catholic Medical Centerarranged for patients to have a dedicatedcell phone line that potentiallyexposed patients could call at any timeof the day or night.Once all patients were notifi ed, hospitalrepresentatives communicated tothe hospitals board, medical staff, themayor of Manchester, New Hampshire,the offi ce of the state governor, and then,all hospital employees. Educationale-mails, meetings, multimedia documents,and other reference materialswere delivered to key stakeholders.The hospital also notifi ed the CEOs ofother hospitals, local business leaders,and even legislators. The hospital helda joint press conference with the stateDHHS and the city public health departmentand a letter to the communityand FAQs were posted on the hospitalswebsite.Soon after these public announcementswere made, news of the contaminatedneurosurgical instruments becameinternational news. The story appearedin the Wall Street Journal , and on CNNand Fox News, among other media outlets.Most media reports were accurate.The hospital communications departmentcorrected errors when needed,and the CEO called all eight patients(or their representatives) to addresspersonally any questions or concernsprompted by the media coverage.To preclude contamination of additionalneurosurgical instruments duringprocedures performed on the potentiallyexposed patients, they were toldto call Catholic Medical Center if theyever needed any surgical or invasiveprocedure. Catholic Medical Center letthem know that they would be contactingthe patients in the future to inquireabout their health and to help answerany clinical questions or handle additionalhealth needs.Perspectives177When hospital leadership learned thatone potentially exposed patient wasto undergo additional neurosurgicaland non-neurosurgical procedures atCatholic Medical Center, the hospitalsupplied disposable equipment andensured that any instruments that couldnot be disposable were quarantinedfor disposal at a future date should thepatient someday be diagnosed with CJD.On September 20, the National PrionLaboratory confi rmed the diagnosisof CJD. In the ensuing weeks, CatholicMedical Center hosted visits fromthe Joint Commission, the Center forMedicare Services, and the Food andDrug Administration. Each made positivecomments about the way that thehospital had handled the incident.A local newspaper praised the hospitalsethical and transparent response. Thisfeedback was disseminated to hospitalpersonnel and the board of directors,many of whom commented on howproud they felt to be a part of such aprincipled organization.The root cause analyses undertakenafter the hospital learned of the indexpatients CJD diagnosis resulted in someprocess changes at Catholic MedicalCenter. New checklists for screeningpatients preoperatively on certain procedureswere instituted. A new alert inthe electronic medical record was builtto automatically notify the chief medicaloffi cer, the vice president of laboratoryservices, the nursing coordinator, andthe infection control offi cer wheneverCJD testing was ordered. Educationand root cause analyses are ongoing,and the hospital continues to provideclinical and educational support forthe eight potentially exposed patients.The chief quality offi cer of CatholicMedical Center presented the case tothe New Hampshire Quality AssuranceCommission, which has representativesfrom all New Hampshires hospitals andambulatory surgical centers.Thus far, one potentially exposedpatient has fi led a lawsuit. Most patientsand their families have expressed gratitudefor the information and supportthey received.Summary and Lessons LearnedEthical healthcare leaders make certaintheir institutional mission and values,including the prioritization of patientinterests, are prioritized over secondaryissues such as fi nancial gain, avoidanceof legal liability, and the protectionof senior management job security.Healthcare leaders need to recognizethat every decision they make on behalfof the organization has the potential todiminish or enhance the moral foundationof the organization. In its core values,Catholic Medical Center specifi callytrumpets compassion, human dignity,excellence, respect, and patient-centeredcare in its mission statement. Therefore,when the leadership of Catholic MedicalCenter aligned its response to potentiallycontaminated neurosurgical instrumentson these values, they exhibited ethicalleadership.A key feature of Catholic MedicalCenters ethical leadership responsewas to signal the specialness and urgencyof the situation. Without the explicitrecognition that an unusual and defi ningethical challenge was before them,leadership at all levels would havebeen less likely to refl ect which actionswere most ethical, or the need to actdecisively. Many subsequent ethicaldecisions therefore fl owed from thisearly articulation that a seminal momenthad come that would test leadershipsadherence to institutional values andjustifi cation of public trust.From this moment, the CEO of CatholicMedical Center felt that his role wasto champion institutional mission andvalues in the face of a challenge. Thisrole conception fi ts the understanding ofPerspectives178moral leadership outlined by Chervenakand McCullough in 2001: 10 that neithercompetent management skills nor protectingthe organizations economicinterest qualify as moral leadership.A moral healthcare executives primaryresponsibility is to lead the organizationtoward the goal of fulfi lling theorganizational and professional moralfoundation of excellence in patient care.Had the CEO instead pursued morepedestrian priorities, such as to aggrandizehis own power in the institution,to appease the interests of key allies inthe organization, or shield the institutionfrom bad press, Catholic MedicalCenters responses to the discovery ofpotentially contaminated neurosurgicalinstruments may not have been asadmirable or effective.Public statements of importanceand urgency of mission are important,but must be followed rapidly by theappointment of a specifi c team whofeels personally accountable for thesuccess of the plan. Examples in theCatholic Medical Center response includeappointment of the chief complianceoffi ce to a key leadership position, andthe identifi cation of a skilled patientnavigator to interface with concernedpatients recently notifi ed of a potentiallylethal exposure. Calling upon individualteam members to align their personalexecution of the CJD contaminationevent response plan was key to ensuringthat the plan was enacted effectively.Attention to such logistical details suchas the creation of a high-performanceteam whose skills, values, and missionare aligned 11 can be crucial to the conversionof ethical talk into ethical action.The prioritization of timely responses,such as communicating to the patientsand the press before a fi nal autopsyevaluation of the source patient, waskey to averting the appearance of footdragging, which could have led toundermining public trust.Following the problem articulation,leadership opted for transparencyand collaboration. Both are critical.In so doing, Catholic Medical Centerwas able to engage regional and evennational expert support, and to show theintegrity of their actions to the public.Examples include strong collaborationwith news outfi ts and state public healthagencies. Such collaboration can entailexplicit recognition of the ego-driventemptation to hide the problem.When the next realization of an ethicalchallenge arises, it can be temptingto develop a short-term plan that givesthe appearance of rectitude but is notfollowed by sustained engagement inpatient-centered action. Therefore, theenactment of a root cause analysis thatresulted in sustained systems redesignhelped protect future patients at CatholicMedical Center from similar risks. Thisexemplifi es the learning health systemin which new evidence is mobilized toredesign systems of care that work betterfor patients. 12 A key feature of suchcontinuous system change activities isthe use of ongoing assessment strategiesthat ensure that change improvesthe quality of clinical care in a durablefashion over time. 13 Therefore, thedevelopment of a long-term patientfollow-up plan and sustained interactionsbetween Catholic Medical Centerand patients, for example, as newsreports evolved, was essential to thedelivery of ethically mandated care inthe wake of the CJD contaminationevent. The articulation of a long-termtimeline with concrete deliverablesthrough the application of qualityimprovement thinking, methods, andassessments tools was a key approachto ensuring sustained engagement andorganizational success.The sustained enactment of plans toensure ethical care for people potentiallyaffected by the CJD contamination eventrequires continuing institutional will.Perspectives179The CEO of Catholic Medical Centerstated he knew I had to be steadfast tothe organizations values and my moralcharacter no matter what we fi ndor what distractions take place. Heresolved personally that the organizationwould focus on what was right forpatients even if, for example, bad pressor legal complications arose, and plannedin advance of his ethical response to suchpotentialities. By succeeding in preservingthe moral foundation of CatholicMedical Center over other considerations,he brought acknowledgmentto a public expectation; a true servicemission.ConclusionsThe Catholic Medical Center response tothe discovery of potentially contaminatedneurosurgical instruments exemplified many facets of ethical leadership,including signaling that a defi ning ethicalmoment had occurred, forming ahigh performing team, communicatingtransparently, and creating a learninghealth system to prevent similar ethicalproblems in the future.The post opinion first appeared on Quality University Essay.