Read the case study and answer the following:

Who are the key stakeholders in this case?

Chapter 9 Information Technology Setback: Heartland Healthcare System

Jack Moore had been frustrated throughout most of his career. Information technology (IT) had been breaking new ground in the medical and corporate worlds for more than two decades, yet Jack found himself continually compromised by unimaginative bosses and organizations crippled by a lack of resources. But it looked as though things were about to change. Jack had recently been hired as the chief information officer (CIO) of Heartland Healthcare System, a successful multihospital system. It was his dream position. The flagship 500-bed hospital was located in the major metropolitan area of a predominantly rural state in the Great Plains region. Heartland's five smaller hospitals of 50 or fewer beds were scattered throughout the rural regions of the state within a 100-mile radius of the flagship hospital. In addition, three specialty hospitals (heart, pediatrics, and orthopedics) thrived in the metropolitan area along with a very busy outpatient surgical center. The hospitals that made up the Heartland system were connected by a sophisticated helicopter transport service that quickly transported patients in need to the flagship hospital. The hospital system employed more than 5,000 staff members and 300 physicians, mostly subspecialists. An additional 900 private-practice physicians had privileges at Heartland. Heartland's staff included a sizeable number of nurse practitioners, who played a significant role in caring for the state's rural population and who also staffed a number of the primary healthcare clinics located in the metropolitan area. When Jack was hired as CIO at Heartland, he was charged with two major responsibilities: (1) ensure access and interconnectivity of medical information among all of the system's hospitals, urgent care centers, primary care clinics, and private physician offices; and (2) determine whether to upgrade the existing patient 131financial system (PFS), which was slated to be discontinued by the current vendor, or move to a new vendor and completely replace the existing PFS with a new product. To make his job easier, he would report directly to the CEO. Richard Smith had been the CEO of Heartland for more than 15 years and was largely responsible for the success of the health system. His one disappointment had been his inability to enhance the IT services available at Heartland. His failure to do so was in some measure attributable to John Forbes, the previous CIO, who was retiring after more than 20 years at Heartland and who was thought to be out-of-date with the currently available technology. Richard had often berated himself for not investing more in IT and for not forcing early retirement on John to better achieve this goal. Richard was pleased with his recruitment of Jack, who had very impressive IT credentials, although not in healthcare, and who seemed competent and eager to move Heartland into the next generation of IT. Richard assured Jack that the needed resources had been budgeted and approved to achieve rapid progress, based on an earlier feasibility study by a reputable IT consulting firm. Heartland had engaged the firm to conduct the study, and both Richard and the Heartland board had been pleased with the firm's work. The IT consultants had indicated in their study that the existing PFS system at Heartland could be upgraded to the new version for a cost of $8 million. An upgrade seemed like a reasonable solution to the immediate problem, but Jack felt it was a myopic strategy if Heartland were to move into future cutting-edge technologies necessary to maintain its command of the market. The plan certainly did not mesh with his personal ambition to build an IT system at Heartland that would be the envy of healthcare organizations across the Midwest. Eager to bring Heartland's system up-to-date as quickly as possible, Richard did not need much convincing of the wisdom inherent in Jack's strategy. Subsequently, a three-vendor search and formal bid process yielded a $40 million contract with MedCore to implement a completely new IT system that fully integrated all clinical and financial functions into a single platform, providing the desired interconnectivity throughout Heartland, its electronic medical records, and its PFSin short, a comprehensive, state-of-the-art healthcare delivery platform. As the project progressed, Jack hired Alan Atkins, a local independent contractor, to manage the implementation and conversion project. The project was a much more complex undertaking than Jack's previous experience had prepared him for, but he felt that with Alan's help, the project would move forward. As work progressed, Jack found himself relying more and more on Alan and his advice on managing the project. Alan began contracting for more and more staff time from his firm to work on the implementation, even though using Heartland IT staff would have been less expensive and certainly better for Heartland staff morale. The staff were beginning to grumble that they were being left out of the loop and did not know what was going on. The sense of being left out of the decision-making 132 Part II: Case Studies and Moral Challengeson the implementation began to escalate as the accounting staff responsible for patient billing and the nursing staff responsible for patient care were ignored. The nursing staff became especially vocal in their chagrin at not being consulted as decisions were made that affected their patient care activities. The vice president (VP) for nursing wasted no time in making her concerns known to the CEO, but they were largely unheeded. Richard thought this was yet another example of the VP's marginal cooperation with other departments in the organization, a problem he had raised during her last annual performance review. To the hospital staff, Jack and Alan seemed to be making decisions in isolation with the unflinching support of the CEO. To Richard, the hospital staffespecially nursingwere being resistant to change as usual and were attempting to thwart the forward progress necessary to bring Heartland's IT into the twenty-first century. As morale plummeted, speculation among the staff began to focus on the appropriateness of Alan's firm's business transactions with Heartland. The purchasing staff let it be known that Heartland had purchased 40 laptops from Alan's firm without a formal bid process. The information security officer complained that Alan's firm had not handed those laptops over to be encrypted per Heartland's information security policy. Making matters worse, Alan's staff were purportedly using real patient records to run test scenarios on their unencrypted laptopsa rumor that was confirmed when a contractor reported that his laptop had been stolen from his hotel room and Heartland was required to file a data breach notification. Then the unthinkable happened. Two years into the contract and $35 million into the $40 million project, MedCore was sold to another company, which dropped the patient billing system product that was an integral part of the project. Nothing in the contract protected Heartland from this scenario. In an effort to minimize the financial loss, Jack went back to the original PFS vendor, who after much negotiation agreed that with the remaining budget of $5 million Heartland could pursue the original option of upgrading the existing system. Richard was dumbfounded. Jack had recommended MedCore so strongly and was so confident that it was the perfect fit for Heartland. Following the initial shock of the disclosure, however, Jack was able to convince Richard that this unfortunate turn of events could not have been foreseen. As Jack put it, it was a minor setback that would not prevent Heartland from moving into the technology future they both desired. In the aftermath of the MedCore debacle, Heartland hired Alan as its full-time manager of hardware support. Jack was shaken by the MedCore departure and believed that he needed Alan even more. It was common knowledge among the Heartland IT staff that Alan had no formal degree. Not only had Heartland waived the position's requirements for Alan, but it had also not posted the position. Today, Richard still has high hopes that Heartland can acquire state-of-the-art technology like that of hardware system giants in the corporate world. Although he Chapter 9: Information Technology Setback: Heartland Healthcare System 133has less confidence in Jack and suspects that Jack is more interested in building his own personal technology empire, he does not necessarily see their goals as being mutually exclusive. Heartland's IT staff clearly lack confidence in Jack's leadership ability. They see a firewall between IT management and the employees doing application support. The nursing staff believe that Jack has no concept of the health system's mission of patient care and no interest in involving patient care staff in technology planning and implementation. The accounting staff are convinced that Jack has no business savvy and does not adequately focus on business applications. In fact, one employee was recently overheard to say, "Jack is more intent on being a cuttingedge IT think tank than being an integral part of a hospital system whose job is to serve patients." Case originally published in a slightly different format in Mistakes in Healthcare Management: Identification, Correction and Prevention, edited by Paul B. Hofmann and Frankie Perry. Copyright 2005 Cambridge University Press. Reprinted with permission. ethiCs issues Management's role and responsibility: What are Richard's role and responsibility in this case? What are Jack's? How does Richard's and Jack's treatment of the other senior staff inform the situation? Were project goals established with metrics to measure progress? Was appropriate accountability and oversight established for a project of this magnitude? Were contracting, purchasing, and human resources practices judicious and ethical? Who is accountable for the security breach that could easily have been avoided if established policy had been followed? Organizational implications: Given the fiduciary obligation of administrators to their organization, how could Richard and Jack have avoided, or at least minimized, the damage caused by their IT plan running into difficulty? Who is more accountableJack, the CIO, for convincing Richard to change plans, or Richard, the CEO, for allowing himself to be swayed without conducting more due diligence? What is the board's role? What are the implications of this situation for quality improvement at Heartland? How will reimbursements be affected? Staff satisfaction? Patient satisfaction? What effect will this failed project have on future staff collaboration and productivity? On staff's trust of management? Adherence to the organization's mission statement, ethical standards, and values statement: Are the actions in this case consistent with the organization's mission statement, ethical standards, and values statement? Was Jack unethical in his management of the IT project? Did Richard behave ethically in his obligations as CEO? Have personal goals and ambitions trumped the organization's mission and responsibility to the community? Conflict of interest: What are the conflicts of interest in this case? Did Jack truly believe that the solution he proposed would provide greater benefit to Heartland and its patients? How might the situation have been different if Richard had examined the interests of all parties (including his own) in an objective way? Use of consultants: What factors should be considered when hiring a consultant? What steps should be taken during the hiring process? Did Jack use his consultant effectively and appropriately? What could Jack have done to improve the situation? Justice and fairness: How do issues of justice and fairness enter into this case? Did Jack manage personnel and other resources fairly? What role did bias play in the situation and its outcome? Did the relationship between Richard and Jack support or inhibit fair and just relationships with others? How did Jack's relationship with Alan affect members of the IT staff? How might the situation at Heartland have been different if Jack and Alan had listened to and engaged other leaders and staff? disCussion by Pete Shelkin and Melissa Cole This case tells the story of a CIO who lands his dream job and is looking forward to making his mark by raising his employer's IT infrastructure to a level that will be the envy of other health systems. Such opportunities can be great motivators because they challenge people to prove their abilities. However, this case also demonstrates that it takes more than desire and motivation to ensure success and that straying from the path to success can be easy once the first missteps are taken. Along the way, ethical challenges arise to which people can increasingly succumb as pressures mount. The following discussion addresses the pitfalls of confusing one's own goals with those of an organization and the consequences of not knowing when to ask for or properly use help. Management's Role and Responsibility Before dealing with ethics, we need to discuss roles and responsibilities. In Richard's case, the board would consider his CEO responsibilities to include setting clear organizational direction, creating the management organization chart, staffing the executive team, ensuring that budgets are set and met, and making Chapter 9: Information Technology Setback: Heartland Healthcare System 135sure that decisions are well made and executed (White and Griffith 2019). Richard has further responsibilities to his management team that include giving each executive clear direction in his or her specific area of responsibility, assessing performance, and providing coaching and guidance when necessary. Finally, as CEO, Richard is also responsible for ensuring that Heartland staff are empowered to do their jobs well and that all of Heartland's patients are treated justly. These actions will ensure that the community's trust is not violated and that patients are satisfied with the services they receive (Morrison 2016). As a member of the senior executive team, Jack is responsible for achieving the goals that the CEO sets for him in ways that will ensure the best results. Those results are typically measured in terms of quality, costs, and benefits. As the CIO, Jack is also responsible for working closely with clinical leaders to ensure that he understands their needs and to prepare strategic and operational plans that take those needs into account. More important, in executing his plans he is expected to meet the clinicians' needs as closely as possible. Given unlimited wants and limited budgets, meeting their needs can be a difficult task, but the expectation is legitimate. Established models and practices show that this responsibility can be successfully fulfilled (White and Griffith 2019). Jack is also responsible for setting clear direction in the IT department and ensuring the just treatment of his staff (Petersen et al. 2018). Finally, as the most senior IT manager at Heartland, Jack has significant responsibility for ensuring that electronically stored protected health information is not accidently disclosed (Shay 2017; US Department of Health and Human Services 2019). The financial management function projects future needs, arranges to meet them, and manages the organization's assets and liabilities in ways that increase its profitability (White and Griffith 2019). Executives have a fiduciary responsibility to protect the resources of their institution. The loss of $35 million and two years of effort opens the door to charges that Heartland's administrators, particularly the CEO and CIO, have failed to uphold their fiduciary responsibility. The board may even ask questions about managerial malpractice and negligence when they learn that the contract with MedCore had no provisions protecting Heartland in the event that MedCore was sold. Although the CEO and Heartland's legal counsel may share in the blame, the CIO has primary responsibility to ensure that relatively common issues with IT vendors are identified and addressed in such an important IT contract. Even if we lay the blame for the troubled IT project at the feet of the CIO, we must still ask what the CEO could have (or should have) done to minimize or even avoid the damage. Healthcare administrators are ethically bound to ensure that staff who work at their institutions are competent (Morrison 2016). This obligation is most clear in the areas of direct care delivery, where many staff 136 Part II: Case Studies and Moral Challengesare required to be licensed or certified and to stay up-to-date through continuing education. Although healthcare executives are not required to be licensed or certified, they are expected to be highly competent in their respective fields, and their managers are expected to validate that competency on a regular basis. A Joint Commission (2017) standard requiring that competency be assessed during orientation helps ensure that every staff member is able to perform and that larger challenges or problems will not develop. In this context, we must ask why the CIO is able to persuade the CEO to ignore the $8 million budget that the board previously approved and to pursue a much more expensive strategy. And then, after the sale of MedCore, why is the CEO willing to believe that the debacle is only a minor setback? Finally, after the VP for nursing voices concerns about not being included in the process, how can the CEO continue to avoid questioning the CIO's ability to do his job? While we may forgive Richard for seeing Jack in only his best light during the hiring process, ethical questions begin to arise in regard to Richard's responseor rather his lack of responseto warning signs about Jack's ability to take direction and his competency in general. At what point between the initial honeymoon period granted to a new hire and the catastrophic failure of the IT project did the CEO fail in his duty to ensure that Heartland had a competent CIO? Could following a schedule of required formal performance assessments that included gathering feedback from others at key intervals have helped the CEO keep the CIO on a course to success? organizational implications Clearly, the loss of $35 million and two years of effort will have a significant impact on Heartland. Not only have the goals of installing a new PFS and ensuring interconnectivity been delayed, but the benefits that could have been gained by spending that $35 million on other capital projects have also been forfeited. Even without further details about Heartland's financials, we have enough information about the size of the system and its operations to make some reasonable assumptions. For example, healthcare organizations with 5,000 employees have about $567.6 million in annual revenue (Computer Economics 2017). We can also assume that Heartland will want to maintain a 2 percent operating margin to achieve an A credit rating (Standard & Poor's Financial Services 2017). Assuming that Heartland is like other midwestern hospital systems of its size, its $35 million loss would have amounted to writing off nearly all of its annual capital budget for the past two years. The lack of corresponding assets on the balance sheet will significantly drive down Heartland's margin and have an adverse effect on its financial and operating ratios. As substantial as the damage appears to be, the picture would be even worse if Heartland's financial performance were below average to begin with. The damage is sufficiently great that the CFO and the board's finance committee will have to make some tough decisions as they watch Heartland's ratios decline and its credit rating get downgraded. The effect on Heartland will likely go beyond the damage to its financial statements and operating ratios and may extend to staff and patients alike. Questions that the CEO should anticipate hearing from the board include the following: What quality improvement initiatives were initially postponed to fund the IT projects, and will they now be postponed even further? Are quality metrics stagnating, or worse yet, declining, while improvement efforts await funding? If so, how will reimbursements be affected now that they are being tied to outcomes? The board may also want to know if staff satisfaction is being affected by delays in improvements and if patient satisfaction is being affected by quality issues, deterioration of the physical plant, or perceptions of outdated equipment. The losses resulting from Jack's actions have implications that reach far beyond the IT department. Given the ethical obligation of administrators to serve in a fiduciary role, how might the CEO and CIO have avoided, or at least minimized, any negative consequences? Why has the original consulting report been discounted? The report was provided by a reputable firm, and the board is pleased with it. Heartland is planning to act on the report's recommendations until Jack arrives and convinces Richard to think bigger. In his enthusiasm to move Heartland into a cutting-edge IT future, Richard fails to exercise due diligence, such as having the consulting firm review Jack's new proposal and compare it with its earlier recommendation. If the consulting firm is truly reputable, and if Jack's plan has merit and is backed by facts, the firm could easily modify its recommendation in light of the new information and Jack's leadership. Given the effect of the change in plans, who is more accountable? What is the board's role? Have they approved the change in plans without asking questions of their own? As tends to be the case when leaders look back at massive failures, they may see many missed opportunities that might have ensured accountability and prudent corrections. Questions also remain about how MedCore was selected and how the project has been managed within the organization. Whether the selection committee included representatives of all stakeholders is unknown; however, Jack's exclusion of key stakeholders from decision-making during the new system's implementation suggests that he also did not consider stakeholder input during the selection process. Ignoring stakeholder input is a primary cause of failure for IT projects (Acharya and Werts 2019). Given that Jack failed to use stakeholder input as the basis of his planning and decision processes, the project would likely have run into serious trouble even if MedCore had not been sold. 138 Part II: Case Studies and Moral ChallengesFinally, there will be tough questions to answer, as well as tough penalties to pay, for the Health Insurance Portability and Accountability Act (HIPAA) violation that resulted from the loss of an unencrypted laptop containing patient data. Because the organization knew about the noncompliance (as evidenced by the complaint of the information security officer) but took no action to correct it, the Office of Civil Rights of the US Department of Health and Human Services will consider this a Tier 4 violationthe most serious type of HIPAA violation, which carries the stiffest penalties (HIPAA Journal 2015). Financial penalties could easily run into the millions of dollars, and Heartland's reputation will also certainly be tarnished by the negative publicity that comes with public disclosure and notification (Shay 2017; US Department of Health and Human Services 2019). adherence to the organization's Mission statement, ethical standards, and Values statement Although we do not have access to Heartland's mission statement and strategic goals, we do know that Jack has two major responsibilities: achieving interconnectivity and upgrading or replacing the PFS. Jack's primary goals are probably tied directly to Heartland's strategic plan, which isby definition and necessity intended to support Heartland's mission and vision. Jack clearly has not met the goals that he was responsible for. However, is failure unethical? One could easily argue that failing to meet a business goal is not in and of itself an ethical failure. To determine the existence of an ethical breach, we need to understand why a failure occurred. For instance, a failure might occur because an unethical person misrepresented his skills or experience to get a job. An obvious example of this in healthcare is someone who impersonates a physician and harms patients by giving bad advice and bungling procedures (Ellison 2018; Martyr 2018). However, Jack appeared to have impressive IT credentials when Heartland hired him and so does not seem guilty of outright fraud. Later we learn that Heartland's project was "a much more complex undertaking than Jack's previous experience had prepared him for." Nonetheless, Jack's willingness to take on such a difficult project would not necessarily be an ethical breach because eagerness to tackle ever greater challenges is often encouraged and admired in successful leaders. What distinguishes an ethical failure from an unethical one is the motive involved (Collins 2018). Jack certainly wanted to make Heartland a successful showcase of technology, but he may have been motivated more by his ambitions than by a desire to support Heartland's mission. According to the opening paragraph, Jack "had been frustrated throughout most of his career" and felt that he had been "continually compromised by unimaginative bosses." Jack's personal ambition was "to build an IT system at Heartland that would be the envy of healthcare organizations across the Midwest." Jack's ambition raises questions about his adherence to Heartland's mission, which focuses on serving patients and, we can assume, makes no mention of causing competitors to be envious. In light of such information, Jack's motives may be questioned, along with the ethics of his priorities and actions. Conflict of interest Conflict is not necessarily bad or unethical. In fact, many innovations have come about because people's perspectives conflicted with the status quo, and their interest in providing a more valuable product or service drove them to challenge accepted assumptions or previous decisions. Some people also discover that they are working for an unethical organization and seek to expose the unprincipled activities. Although such whistle-blowers are motivated by the conflict between their personal interests and their responsibilities to their employers, they are usually regarded as acting ethically. In the end, the determining factor is the whistleblower's motivation: Is the individual focused primarily on personal gain or on the benefit to the organization? In the case under consideration, the goals of the CIO, the CEO, and Heartland initially appear to be aligned: They all share the goal of using technology to move the health system into a productive and efficient future where quality rises and cost per unit of service declines. Conflict comes into play almost immediately, however, when the CIO decides that the board-approved solution is myopic and lobbies successfully to pursue an alternative strategy at a much higher cost. Where do the CIO's interests lie when he persuades the CEO, and presumably the board, to change direction? Does he believe that his solution will result in greater benefit to Heartland and its patients? Perhaps he does; however, we are told that a primary reason the CIO believes that the approved solution is shortsighted is that it does not mesh with his personal ambitions. When that is considered along with the statement in the opening paragraph that the CIO had felt "continually compromised by unimaginative bosses" throughout his career, we get a sense that while the parties' goals may be aligned, their motives may not be. The term conflict of interest is commonly used to describe such situations; perhaps the term conflict of motive can be thought of as the key to identifying a conflict of interest that is unethical. In the Heartland case, other interests besides those of the CEO and CIO are at play as well. For example, the CIO's interests seem to conflict with those of the VP for nursing and her nursing staff, the accounting staff, and the IT staff. While 140 Part II: Case Studies and Moral Challengesmounting evidence suggests that the CIO's selfish motives are at the root of those conflicts, each interest should be examined on its own merits. All too often, a mob mentality can take over when a crisis reaches critical mass and people rally to find a scapegoat. To guard against a situation such as that at Heartland, people must avoid accepting the easy conclusion and falling into an ethical trap. The CEO's actions are evidence of this tendency: Instead of fully investigating the situation, Richard quickly dismisses the nursing VP's objections because he sees them as proof of her marginal cooperation. In fact, as the project gets deeper and deeper into trouble, the more others complain and the more they are ignored. How might the situation have been different if the CEO examined all parties' interests and assessed the validity of each perspective? use of Consultants Healthcare leaders must frequently decide whether to use internal talent or outside expertise. Large IT projects are especially likely to call for such decisions because the needed skills and the duration of those needs usually differ greatly from the needs of day-to-day operations. Ideally, when organizations hire consultants for temporary support and enhancement of their own staff, the staff gain valuable new knowledge and abilities. Laying the foundation for a successful collaboration requires input from the project's stakeholders to clearly define the scope of work to be accomplished, as well as thorough research by the in-house project manager to locate a consultant with the right skills, experience, and credentials. A contract is then negotiated that documents the scope, the deliverables (which should include knowledge transfer), and a clear timeline that includes project benchmarks. (Of course, use of consultants for open-ended operational activities would not require such a strict plan.) At Heartland, the CIO seems not to have taken any of those steps when hiring his consultant. He instead hires a consultant who can make up for his own lack of experience: "This project was a much more complex undertaking than Jack's previous experience had prepared him for, but he felt that with Alan's help, the project would move forward." In short, Jack creates a situation that discourages the consultant from transferring the knowledge needed to sustain the new system because, from the consultant's perspective, doing so would bring an end to what has turned out to be an open-ended, lucrative project. In addition, the consultant's lack of credentials, compounded by his inability to connect with the VP for nursing and other leadership, leaves him open to criticism and takes a toll on staff morale. Clinical, accounting, and IT staff all feel left out of the decision-making and therefore have no buy-in to the project or its success. The Code of Professional Ethical Conduct of the American Medical Informatics Association states (Petersen 2018): Recognize technical and ethical limitations and seek consultation when needed, particularly in ethically conflicting situations. Has Jack followed the AMIA's code and admitted his technical shortcomings? On the surface, his choice to use a consultant implies that he recognizes the gap in his abilities. However, instead of expanding his own abilities or those of his staff, he appears to use company resources to keep his shortcomings covered up. By failing to define the roles of his consultant and his IT staff, the CIO also opens the door to dissension and frustration: He does not engage his staff in the knowledge-building process, and his actions create a wedge as opposed to a bridge. Although he is ethically bound to ensure that the goals and activities of his department are aligned with Heartland's mission and vision, Jack's pursuit of his personal goals creates an environment that is counterproductive and distracting for his team. The CIO has painted himself into a corner and feels forced to convert what should have been a defined consulting project for Alan into a permanent job. By ensuring that Alan reports directly to him, Jack ultimately removes the need to improve on his own skills. Justice and Fairness Richard and Jack certainly have focused goals: move forward with replacing the PFS; create a legacy of supporting patient safety; and provide a fully integrated, state-of-the-art IT system for use by staff across the enterprise. Their vision is clear, and the resources they need seem readily available; yet when they begin working toward achieving those goals, they are unwilling to listen to stakeholders, especially those with differing views, and thus fail to find common ground. All people have biases, and if pressed, most will admit to them. Fair and just leaders know how to identify potentially damaging biases and keep them in check. They also know that openly disclosing affiliations and financial ties helps clear blind spots, reduces liability, and increases the trust of staff and colleagues. Consider why people develop a bias toward a favorite source of input. Is it because that person helps them come to the best conclusion and grow in the process? Or because that person fills a gap that they have and helps them avoid detection? Which reason best explains the relationship that Heartland's CIO has with the IT consultant? How may the CIO's waiving of Heartland's hiring criteria for the hardware support manager position be viewed by the IT staff, particularly those who may actually have qualifications for the position that the consultant lacks? Managers may naturally gravitate toward one or two staff members when they seek advice. We all seek advice from people who have the skills and experience to help us. The way a manager responds to input from people other than trusted advisers can raise ethical questions, however, especially when that input conflicts with the manager's point of view. To be fair, the manager should listen to all opinions with an open mind. Clearly, Heartland's CIO has not done so. By failing to listen to those he viewed as critics and adversaries, he has failed to include information that may have helped him create the most serviceable IT system for all users (Acharya and Werts 2019). Heartland's CIO and CEO have allowed their biases to influence whom they listened to. Would a strong focus on fair and equitable treatment have helped them avoid the compromising situation that they now find themselves in? Imagine if the CEO had listened without bias to nursing and accounting staff and put them in leadership roles on the project. Consider how working conditions might have changed in the IT department if the CIO had listened to his team as much as he listened to his consultant. In a fair and just organizational culture, an IT project would turn out quite differently than did the project at Heartland, where the CIO and CEO gave in to their biases. Fairness does not imply consensus seeking or weakness, nor does it mean compromising on goals or outcomes. Ethical and just leaders do not choose sidesthey maintain their vision of success for all. They bring dissenting voices together via shared goals. People often have differing opinions about "how." The true, ethical leader reminds them of "why." Lessons Learned The Code of Ethics of the American College of Healthcare Executives (2017) states: The fundamental objectives of the healthcare management profession are to maintain or enhance the overall quality of life, dignity and well-being of every individual needing healthcare service and to create a more equitable, accessible, effective and efficient healthcare system. Healthcare executives have an obligation to act in ways that will merit the trust, confidence, and respect of healthcare professionals and the general public. It also enjoins us to "use this Code to further the interests of the profession and not for selfish reasons." These passages provide a good ethical framework for examining the case of Heartland Healthcare System. In the Heartland case, the CEO and CIO are quite shortsighted as they move forward with system integration and modernizing the PFS. Despite many Chapter 9: Information Technology Setback: Heartland Healthcare System 143setbacks, the CEO remains satisfied with the CIO's performance and seems unable to respond to feedback from others to the contrary. While he has "an obligation to act in ways that will merit the trust, confidence, and respect" of his executive team, he does not listen to his VP for nursing and thus erodes her trust. He also minimizes the complaints of Heartland's information security officer, which may result in financial penalties and damage to the organization's reputation. Healthcare leaders must give everyone a chance to be heard, even when the motivation behind dissenting voices might be in question. In a highly engaged team, all ideas are not necessarily supported, but all voices are heard. Ensuring that level of engagement is the responsibility of every leader, especially the CEO. At Heartland, the CIO becomes increasingly dependent on the consultant, and in doing so he allows the balance of power to shift away from his team and to an outsider. This dependence causes growing concern among others in the organizationconcern that is compounded by the CIO's failure to consider their input. Leaders must communicate when their abilities are stretched. Asking for help is indeed a challenge. All people strive to appear competent, and many worry that by asking for assistance or admitting they do not have all the answers, they risk exposureor worse, repercussions. Successful leaders understand their shortcomings and use help in targeted ways for specific results. Less successful leaders sometimes use help as a cover, hoping that the helper will solve all the problems before they fully manifest themselves and derail a project. Following are steps to take when help is needed: 1. Learn to recognize an error. First, assess if an error has been made. If so, immediately confer with an executive stakeholder who can assist with any course corrections. Ethical leaders monitor themselves, recognize errors, and model to staff how best to respond to mistakes. 2. Be willing to seek specific help. Identify personal strengths and weaknesses, and recognize when help is needed. Be specific about the help needed by clearly defining the tasks, roles, and outcomes sought. Be clear about what you know, what you need from others, and what you expect moving forward. By defining the need and the expectations, you make the distinction between using help and being helpless. 3. Engage others. Connect with others early and often to gather relevant information and develop strong employee involvement. This can be the most valuable time you invest in a project because collaboration improves outcomes. By engaging others from the beginning, you may be able to prevent an error or avoid the need to ask for help later. If you recognize the need for a course correction, promptly acknowledge any error and then ask for help. Demonstrating humility and acknowledging what others can contribute will earn the trust needed to move forward. 4. Request feedback. Seek counsel from peers, stakeholders, and supervisors. Reach out to a mentor, ideally someone outside the organization, who has succeeded with similar projects. After making (and admitting to) an error, engage people of influence to ensure a turnaround and success. 5. Remain open. Keep firmly in mind that the concerns voiced by people you may perceive as resistant could have some validity. Get past your preconceptions and hear the true message. Do not alienate people whose support and guidance you may need in the future. 6. Focus on the solution. Once an error or misstep has been acknowledged, gather your team and begin working to correct it. Recognize that even individuals who have resisted your plans likely share your goal: to make the organization more successful. Focusing on the solution overcomes any unpleasantness caused by disagreement. Also, giving detractors a role in planning the solution ensures their buy-in, which will be critical not only for the success of the project but also for sustained operational success. Healthcare IT is evolving at a rapid rate, and no one person can have expertise in every area. Acknowledge when additional expertise is needed and engage stakeholders to ensure adoption of proposals and their cost-effective implementation. Perhaps the most significant ethical lapse by Heartland's CIO is to disregard his responsibility to identify when the project's demands have exceeded his technical ability or to draw on appropriate resources and stakeholders to ensure the project's success. By not engaging key stakeholders or asking for feedback and by attempting to do everything on his own (helped only by Alan), Jack has alienated all of the team members he needs to successfully define and implement his project. Ultimately, the ACHE Code of Ethics identifies healthcare leaders' responsibilities in six key areas (ACHE 2017): 1. The profession of healthcare management 2. Patients or others served 3. The organization 4. Employees 5. Community and society 6. Reporting of violations When healthcare executives lose sight of their mission or lose their ethical grounding, they tend to make poor decisions. Poor decisions result in criticism, and if they fail to respond properly to justifiable criticism, they lose the trust of those Chapter 9: Information Technology Setback: Heartland Healthcare System 145they lead or serve. As Greer (2012) observed, "in the absence of trust, we try for control," and the Heartland case illustrates that trust cannot be won back simply through the exercise of control. Ideally, we all have an ingrained set of ethicsan internal compass that helps us differentiate between right and wrong. When we find ourselves confronted by an ethical dilemma at work, we can reach into our professional toolbox, which includes our mentors, our colleagues, and our professional code of ethics. Our code of ethics is the foundation of all our activities, decisions, and behaviors; by broadening our perspective, it enables us to see beyond our personal interests and pursue higher goals. The leaders in this case had wonderful intentions. When their project became too difficult for them, however, they reacted by trying to hold onto control instead of admitting that they needed help. Had they behaved ethically when problems arose instead of becoming entrenched in a battle for control, the outcome probably would have been much different.