Braveheart Medical Center is a Baptist institution with a proud history in a lower-income urban community. Recently Braveheart has, like other, wealthier healthcare organizations, struggled to make ends meet. One of Braveheart's core faith-based values is stewardship. Senior leaders have made a point of reminding associates, especially middle managers, to "consider stewardship" in all their decisions.
For three years, Donna, a clinical manager at Braveheart, has been telling her director how much her medical-surgical unit needs an information systems upgrade. Last year the director virtually promised that the upgrade would be approved for fiscal year 2002. Now, unfortunately, Donna's request appears to be a casualty of the tight financial situation. "You know senior management made it clear that we must be good stewards," her superior says. Later, Donna says to another clinical manager, "We desperately need this upgrade to make it easier to enter orders, and it would dramatically reduce the risk of serious mistakes. They know that, but all I hear is how we can't afford it because of 'stewardship.'"
Many healthcare organizations, especially those with religious missions, embrace stewardship as a core value. The term has rich associations. Historically, a steward was a person entrusted with resources—money, people, or goods—belonging to another, who would in turn expect an accounting of how and to what advantage the resources were used. By analogy, Jewish and Christian traditions portray human beings as stewards of God's gifts or resources, including life and health.
Today the term's historic meanings are either unknown or easily forgotten in the pressure of daily decision making. Moreover, the specific meaning of stewardship in a given situation is seldom crystal clear. Core values are, by nature, stated in global or general terms and are inherently subject to multiple interpretations.
In addition, understandings of core values are influenced by people's location in the organization and the role they play in providing or supporting patient care. As a manager, Donna's director feels pressed to economize wherever possible. Believing that senior leadership equates stewardship with frugality, she aligns her approach with that view. In effect, her reference to stewardship serves as shorthand for "We can't afford it."
There is some risk in appealing to core values, even those associated with a religious mission, as a rationale for particular actions. Divergent understandings and inconsistent application are quite possible unless those who must implement the value receive guidance in its application, or themselves think through its specific implications. If stewardship, for example, is used solely to justify fiscal limits and restraint, people may become disenchanted, even cynical, about the value itself. Donna's reaction suggests that she has interpreted her superior's words in this way.
Donna, of course, sees things differently. One might say that she has different value priorities, such as an overriding commitment to quality patient care. Conflicts involving stewardship are often framed as conflicts between stewardship and some other important value. If, for example, another of Braveheart's core values is quality, one might contend that her difference with her director reflects a conflict between Donna's emphasis on quality and the director's emphasis on stewardship.
Perhaps, however, Donna's words to her colleague hint at a variant conception of stewardship itself—a concept that she does not fully articulate, and might not even recognize as stewardship. In mentioning improved processes and enhanced patient safety, she draws on her responsibility for managing patient care. This suggests that her concept of stewardship encompasses the use of resources to achieve improvements in both process and outcome.
It is clear that stewardship is no mere frugality principle. In health care, it is generally understood as a value requiring the best use of resources to achieve important ends, such as supporting and enhancing optimal patient care. Insofar as protecting patient safety is indispensable to such care, paying for technologies that promote safety may be a significant expression of stewardship.
At the same time, stewardship typically implies effectiveness and efficiency in achieving desired aims—here, arguably, it overlaps with quality. Thus, its specific meaning in this case can include estimating current safety risks and the risk reductions an information systems upgrade might yield. The results of such an assessment would likely be weighed against the expense of the new system. In the end, decision makers might still determine that denying Donna's budget request is the best way to implement stewardship. Such an outcome, however, would result from a process quite different from the blanket application of a frugality principle.
In hard times, when every dollar seems precious and each expenditure receives extra scrutiny, the horizon of people's vision often narrows. A term like stewardship can become a slogan or euphemism, ironically obscuring the very needs and specific values it is meant to support, or even arousing suspicion. Senior leadership, an ethics committee, and/or a values integration team can assist managers—and all associates—by promoting a positive yet realistic vision of stewardship. Communication throughout the organization could portray stewardship as the judiciously enterprising use of always-limited resources in ways that demonstrate the compassion and competence of staff members' care. Such communication will not eliminate the financial pressures that leaders and middle managers face. But it can help everyone cultivate a broad perspective on the continuing need—and opportunity—to use available resources to optimal advantage in fulfilling the organization's mission.
