A Possible Diagnostic of the State of Health of Ethics Management in the Hospitals in Romania an Exploratory Study

Background . Our article presents the results of an empirical study having as objective the identification of the preoccupations for the management of ethics, the formal or informal ethics programme existing in the practice of the Romanian hospitals. Methods . Our exploratory qualitative research is based on semi-structured interviews, conducted in 2016 in the hospitals in Romania. A number of 19 respondents from nine hospital units in several towns in the country have participated. Results. Our research reveals that the ethics management system in Romanian hospitals is strongly limited to the applying methods and tools to comply to the legal requirements for the healthcare sector activity and mostly focused to the activity of the Council of ethics (organism founded by law, that functions in the hospitals), but a holistic and integrated approach is still missing. Conclusions .  As a general conclusion, we notice the managers‘ awareness of the importance and need to implement an ethics management system, but this is a field that requires more attention and clearly improvement in the Romanian hospital units in terms of vision and systemic approach, ethical culture and leadership, ethics system, policies and programs. The study could be useful first to all hospital managers in improving the global performance and ethical reputation of their unit, but also to public authorities that adopt policies in healthcare system, to accreditation bodies and academics interested in this research area.


Introduction. The necessity of ethics management in healthcare institutions in Romania
The necessity to adopt widely an integrated system or a programme of formal management of ethics in the medical institutions in Romania is felt increasingly much. Much public unrest is felt more and more. Much public unrest proves the lack of awareness and assuming the ethics values and responsibilities by all the social actors that are involved, and it manifests itself not only in the field of clinical services, the patients" treatment, but also the respect for their rights. The lack of ethics preoccupation means vulnerability also in different managerial areas or activities: the management of human resources and leadership ("Bribes for jobs and poor salaries throw medical care into crisis as doctors desert the country in droves"), (Stancu, 2014), the lack of transparency in making decisions, the faulty management of resources, the low quality of the medical services offered.
Informal payments still remain as a practice specific to the Romanian medical system, but it is also found in other countries as well. According the Special Eurobarometer 470 published in 2017 (European Union, [EU], 2017), 31% of Europeans consider that the corruption "is widespread in healthcare system" (EU, 2017: 21). In Romania (as also in Greece, Cyprus, Lithuania, Slovenia and Slovakia (EU, 2017: 22), the healthcare system was one of the most frequently mentioned as a corrupted system. 19% of Romanians say that "they had to make an extra payment on top of the standard fees" (bribe) (EU, 2017: 85). To that corruption problems are added, in the public purchase at national level (for example the scandal of some very diluted disinfectants started in 2016 in Romania, that was widely reported in international media; McGrath, 2016;Haraga, 2016), the violation of law, etc.
The aspects mentioned above are only some of the visible signs of the weaknesses related with the ways which the organizational ethics processes are carried out in healthcare institutions. Many of such behaviours have as source the lack of ethics rigour and an ethics system consolidated by an efficient and effective management. All these negative problems are often presented in the national media, and even internationally, which affects irreparably the trust in the Romanian system of healthcare.

A short overview on ethics programs and compliance
As Pearson, Sabin and Emanuel (Pearson, Sabin, & Emanuel, 2003: 40) stated, "Organizational ethics is the new frontier in the ethics in the field of healthcare". A comprehensive definition of the healthcare organisation ethics is offered by Spencer at. al (2000, cited by Mills & Wicks, 2005: "[..] processes to address ethical issues" related with the main operational areas and organisational relationships. Mills & Wicks (2005: 223) add that this definition "includes the articulation, application and evaluation" of the organisational mission and values.
The management system of ethics is equally important and must be authorised as the other systems or sub-systems belonging to the organisational management.
In its approach to clarifying the concept, Muel Kaptein (1998: 43) considers that ethics management is about "[..] making a description and analysis of the current situation, determining the desired situation, deciding which measures should be taken and activities implemented, and integrating this into the organisational context". The mentioned author classifies it as being a management discipline.
In this light, we consider that ethics management involves the processes (and its implicit systems) of planning, organizing, leading and controlling needed to fulfil the ethical standards in all internal and external organisational activities and in its relationships with stakeholders.
According to Treviño and Nelson (Treviño & Nelson, 2011: 245), the large organisations that deal with the compliance to ethics standards in all the activities are prone to implement formal systems of ethics management comprising: an office of ethics, an officer of ethics, explicit programmes of formation in ethics, a line /phone of counselling/report of ethics problems, and a system of investigation and monitoring the reports regarding the deviations from the ethical behaviour. The authors underline that however the context, the culture of the organization, the sector where it is active (which can put more stress on observing the legislation) are factors that influence this system. Also, they mention that the best formal programme of ethics management comprises the "compliance to law within a wide set of organisational values" (Treviño & Nelson, 2011: 245).
The literature in the field and the practice of the organizations promotes in this sense the ethics and compliance programme.
Numerous authors and professionals express their opinion regarding the favourable role of the ethics (and compliance) programmes in the organizations. The ethics programme is a must, which facilitates the early discovery of the problems in the organization and their solution with minimum cost and publicity (Anonymous, 2004: 6). The two challenges of building a sound programme of compliance are the encouragement of employees to adopt the ethical behaviour and the efficient measuring of the ethical behaviour (Bikard, 2011: 56).
According to the practitioners (Anonymous, 2004: 6), an efficient programme of ethics and compliance should contain four elements: written standards of behaviour that mention clearly the behaviour considered to be adequate at the work place, the ethic formation for all the employees (the ethics policies of the organization, debates about them, applying elements in some hypothetical situations), lines or officers of counselling in ethics (the employees should have the opportunity to ask about ethic matters, without fearing retaliation), systems of anonymous report for inappropriate behaviours . Melinda Burrows (Burrows, 2006: 21) mentions as advantages of a programme of ethics and compliance: it prevents the deviation from the ethic behaviour; it gives the organization the possibility to detect on time the illegal behaviour, diminish the risk and manage the internal investigation; in the case of some illegal behaviours not detected on time, it can be useful to persuade the authorities not to punish the company or penalize it very severely; there is the probability for the judges to consider that the programme is a factor that contributes to setting minor juridical sentences; it offers tangible proof that managers and officers fulfil their fiduciary obligations to protect the company"s assets, diminishing the risk of civil responsibility by applying some investigations in case of employees" behaviour deviations.
These programmes "help detect the crimes, favour the rapid investigations and minimize the consequences"; in case of investigations, it proves the ethical and legal positioning of the organization and contributes to the reduction of penalties, in the situations where it is found guilty of inappropriate deeds (Stouffer, 2006). Roy Snell (2007) suggests an approach of the programme of ethics and compliance from the perspective of considering the elements of the programme according to the pyramid of needs by Maslow. In Snell"s opinion, the ethical behaviour is rather a result (or a set de expectances, the ideal targeted, self-realization), and compliance is a process that leads to it. The programmes of compliance "are necessary to offer clarity in respect of the rules and regulations, audit and monitoring to evaluate the compliance and the discipline to maintain the ethic behaviour." (Snell, 2007: 33). Thus, on taking into account the basic elements of a programme of ethics and compliance, and the principles of functioning and the ranking of needs in the Maslow"s pyramid, at the base are placed the discipline and corrective action (on the level of the physiological needs), audit and monitoring (on the level of the security needs), policies and procedures (including the ethic code) corresponding to the social needs (love and belonging), formation/education about ethic behaviour (in agreement with the need of esteem), ethics or ethic behaviour (on the level of the needs of self-accomplishment, fulfilment).
Muel Kaptein (2015) underlines the fact that adopting an ethics programme is beneficial to the organizations, the appearance of non-ethical behaviours being lower in them, comparing with what happens in those where this type of programme is not implemented. Also, according to the research of the author mentioned, there is a direct relation between the number of the programme components and the frequency of the non-ethical behaviours noticed. Thus, the author identifies and analyses nine components, and the sequence of the efficiency of their approach is: 1code of ethics; 2 -programme of formation and communication; 3 -policies of accountability; 4 -monitoring and audit; 5 -policies of investigation and correction (these first elements being directly related to the lower presence of non-ethical behaviour), followed by the existence of the 6 -officer of ethics, 7-line of ethics report, 8 -policies of stimulation (indirectly related to the lower presence of non-ethical behaviour). The study did not validate a relation between the evaluation of the candidate before employment and the lower presence of the non-ethical behaviour, the strongest being though with the policies of accountability.
In spite of the mechanisms imposed by law (the existence of the counsels/committees of ethics and the commissions of ethics), there are numerous non-ethical behaviours in organizations, which demonstrates the necessity at institutional level of some programmes of ethics, complex, complete, coherent, including the monitoring, which should be according to the mission, vision and strategy of the organization.
The U.S. Sentencing Commission (Wulf, 2011: 104-112) has introduced by the Amendments in 2004 a programme with seven elements that guide the organizations to organize a programme of ethics and compliance, by which it is shown the expectations of the government in this sense: setting clear standards and procedures to prevent and detect nonethical behaviours and law violation; organizational leadership and corporative culture; reasonable efforts to exclude the people who create problems in the organization; creating programmes of communication and formation on the topics of ethics and compliance; monitoring, audit and evaluation of the efficiency of the programme; rewarding the performance June, 2018 Openings Volume 9, Issue 2 230 and applying disciplinary actions; reactions and modalities of response in case of non-ethical and illegal behaviours, and setting remedy actions. An essential element, the field where the ethical infrastructure is built is an ethical culture, which leads to several advantages in the organization (Ethics Resource Center [ERC], 2009): it offers the possibility to create a culture of stronger integrity; it teaches people the aspects that lead to a wrong direction; it helps to identify the items that can be included in the analysis of the ethic risks; it offers a "list of verification" with the problems and aspects that are related with law violation. The United States Sentencing Commission decided in April 2010 to modify the Federal Sentencing Guidelines addressed to the organizations, including the dispositions targeting the future attributes of efficient ethics programme and compliance. Nick Ciancio (2007) considers that the programme of ethics is "the key element for the culture of integrity." The author refers to the Federal Sentencing Guidelines (FSG), and mentions the seven poles that support an efficient programme of ethics and compliance: standards and procedures (often in form of the code of behaviour; they must be communicated to the employees in order to adhere to them; they show which are the expected behaviours and often are a key element in their evaluation); monitoring (the need for a strong leader that can monitor all the elements of the programme; it can involve also an officer /department/committee of compliance according to the size and necessities of the organization); education and formation (continuous, for the employees to understand the standards and procedures); audit and monitoring (of the internal systems and to check the compliance; the activities can be carried out by the officer of compliance, but it is recommended the appeal to internal or external auditors; it must comprise all the medical units and especially the contractual relations with third parties, respecting the financial and accountancy procedures, of the national programmes of healthcare, etc.); reports (mechanisms available for the employees to make accusations (fraud, no-ethical behaviours, noncompliance) or signal various preoccupations, without the fear of retaliation; it can be an anonymous phone line, lines to report on the website); consolidation and discipline (setting rules generates consequences, and there must be constant awareness about them, regardless of the employee"s position in the organization); response and prevention ("the organization must respond" in case of violations, and make permanent efforts to prevent them).
Assuring the efficiency of the programme of ethics and compliance could be done only if there is a process of evaluating the risk ("the identification and evaluation of the operational and organizational risks" and applying measures to minimize them (Baker, n.d.). This process has the role to evaluate the risk of producing behaviours that violate the standard of compliance to law and ethics, taking the necessary measures "to design, implement and modify any request"… "in order to reduce the risk of identified criminal behaviour" and "promote the organizational culture that surrounds the ethical behaviour and the commitment to respect the law." Professionals in public health have minimal formation in the ethics analysis (Roberts & Reich, 2002: 1059. The research carried out by Barker (1993: 165) to evaluate the efficiency of the programme of ethics implemented at the company General Dynamics proves that not all the programmes completely reach the objectives initially planned. Thus, in the case of this company, the programme reached the specific objectives (communication with the employees about the rules and standards of behaviour that must be respected and the improvement of the company image), but not also the implicit ones, wider (it was not obtained a work environment "more humanistic" for the employees, favourable to the "individual dignity, the mutual respect, which promotes a honest treatment of the employees by the managers; it was not built the trust between these two parties). The observations of the research prove that all the necessary steps for the development and implementation of the programme were followed: its formal definition, the communication to all the employees, their formation and accountability in respecting the rules and standards, the implementation by means of the executive decisions of the procedures of standard operation and corporate media. Self-assessment was used (feedback questionnaires), corrective measures were applies to consolidate the compliance to rules and standard. Before implementing the programme, external agents were contacted to carry out the change, the internal agents being carefully selected. The author"s conclusion for the research is that by the standards targeting the humanistic treatment, the initiating managers of the programme wanted to create rather "a supportive frame" for the employees, to encourage them to respect the rules, the purpose of the programme being actually the compliance. The company used "a sale technique" of the programme, appealing to the emotions of the targeted audience, but raised unrealistically its expectancies ("being ethical means good business, and being ethical will consolidate the life quality at the work place"). Barker"s (1993) research deserves to be mentioned from the perspective of the experience of a company in implementing a programme of ethics, of the necessary elements that must be applied, but also the mistakes made by the managers by what they communicate to the others, or the risks in obtaining the efficiency of the programme.
In her article, Megan Barry (Barry, 2002: 37) covers a list of reasons ("dangers") for which these programmes of ethics and compliance can fail: the standards are inconsistent (there is no set of articulated values that are spread in the company; superior management limits its ethics approach by not creating a global standard of ethics; the lack of involvement from the side of the council of administration in creating the code of ethics and an ethic environment; inconsistence of the messages included in the code of ethics; unrealistic policies and procedures, which the employees will tend to break regularly); lack of support from the officer of ethics (who does not have enough delegated power to carry out their work efficiently); weak communication (the training programmes are singular and not everybody has access to them); the support systems are weak (the employees do not actually have a safe and trustworthy way, anonymous, without suffering from retaliation) to report the deviations from the correct behaviour noticed in the organization; there are no ways to consolidate the standards (applying the disciplinary measures is applied inconsistently, based on the level of the offending person).
Curtis C. Dubinsky and Joan Verschoor and (2003: 16-18) recommends and presents in detail ten steps in carrying out an effective ethics programme: going through rigorous self-evaluation (the values of the organization; how much the employees believe in values; already existing elements specific to the programme; what should be created new); assuring the commitment of the superior management of the organization (which results the superior managers want to obtain, how they describe what will be obtained differently after the implementation, how they prove their dedication to this programme, if they are neuter or employed from the ethical point of view); publishing and distributing the code of ethics (whether there is written guidance for the employees and stakeholders, whether the employees know what the organization expects from them, whether they can utter, read and apply lines of guidance, whether there are policies and procedures available and whether the latter are adapted to the average level of understanding of the employees); communication [repeated] (how the messages are communicated, whether the employees know and believe in them, the key messages that must be repeated, the management of change, the use of multiple channels to transmit the messages); formation (the way to consolidate the messages, the regular formation of the employees in applying the values and rules, the formation of the employees" ability to exercise their moral reasoning); assuring confidential resources (where the employees can go to express problems, preoccupations, complaints regarding non-ethical behaviour, how functional and trustworthy these resources are, where it is reported only to the supervisor or there are also resources (of report) confidential and alternative, the maintaining of confidentiality, the possibility of anonymous report, consequences/measures after the report); the consistent implementation (the functioning without problems and effectively of the system, the functioning of the programme, in all the organisational units, the clear and documented definition of the roles and responsibilities); prompt and honest response and consolidation (consistence in applying values, standards and rules, recognition and reward for the adequate behaviour, the way of carrying out the internal investigations, the uniformity in applying disciplinary measures, treatment of people with high performance when they violate the ethic standards); monitoring and evaluation (evaluation of success, feedback offered to the employees during internal controls); revision and reformulation (permanent update of values, rules and the content of the programme, continuous improvement).
Evan A. Peterson (2013) analyses the ethics programme and compliance from the perspective of the report of the business to law (on taking into account the fact that in the United States of America these programmes have obtained their status by the Federal Sentencing Guidelines for Organizations from 1991 (Joseph, 2002), as a strategic instrument to gain a competitive advantage. In this approach, he proves that by the stress placed on "facilitating a more advanced understanding of the juridical environment, the suggestion of more efficient means of approaching and preventing the legal violations and by encouraging the perception of the juridical problems as opportunities of business, the ethics programmes and compliance assist in the elaboration of the action plans to get a competitive advantage based on law." The main premise of research from which the study started is that the institutional efforts for the ethics management in the Romanian hospitals are not approached systemically and systematically, but only at a basic level, focused mainly on the requirements imposed by the specific regulations in the medical system in our country, and on the activity of the specific organisms imposed by the law. There are not a global, holistic, supplementary and voluntary efforts, from the side of the managers and the organization.

Methods
The method of research is qualitative, based on semi-structured interview.
The research population. The respondents are people involved in the managerial activity in the hospitals in the country. Choosing the type of subjects is justified by their capacity to have direct or indirect access (global vision at institutional level, competence/formation, authority and responsibility, resources) to know, understand and manage the ethics system /programme (existing, formal or informal) in the institution.
The method of sampling and sample. The method used was nonprobability sampling, intentional (purposive sampling). The respondents were contacted directly on the phone or face-to-face and, according to their availability to participate in the research, they received afterward in email or on hardcopy the interview grid. The final sample is formed of 19 respondents from nine medical units (an institute of oncology, a hospital of recovery, an institute of psychiatry, a hospital of lung-physiology, a hospital of chronic diseases, a clinic hospital of infectious diseases, two municipal hospitals, a city hospital) from five cities and towns (including from the capital) in Romania. According to the official classification on categories of the Romanian hospitals based on their competency (http://www.ms.gov.ro/?pag=53), two hospitals are ranked in the first category, four in the second category and three in the fourth category. Four of them are also university hospitals.
Respondents' profile. Six public hospital managers, eight medical directors, three economic directors, and two directors of medical care participated in the interview. Ten respondents are females, nine are males.
As for the age, ten respondents are aged 46-55, five respondents are aged 36-45, four are aged over 55.
Based on the years of work in the organization, five respondents have more than 20 years of work, five participants between 6-10 years seniority, five respondents have less than 3 years of work, three of them between 16-20 years of work, and one has 11-15 years of work. When it comes to the number of years in managerial position, eight of the participants in the study have 1 to 3 years of work, four participants between 5-10 years, three participants have more than 10 years, two of them between 3-5 years, and two respondents less than a year of seniority.
According to the type of studies, 13 respondents have medical studies, 6 of them have socio-humanistic studies. According to the level of studies, 9 respondents have bachelor degree, 3 have a master"s degree, and 7 have PhD studies. Among the 19 respondents, only 14 have basic managerial formation in management, and only 3 of them have formation in the field of ethics.
According to the specialization of the hospital, four respondents are from an institute of oncology (manager, medical director, economic director, care director), two respondents are from a hospital of recovery (manager, medical director), one respondent from a hospital of chronic diseases (medical director), one respondent from a hospital of lung-physiology (manager), four respondents are from two municipal hospitals (manager, two medical directors, an economic director), a medical director from a clinic hospital of infectious diseases, four respondents from an institute of June, 2018 Openings Volume 9, Issue 2 236 psychiatry (manager, medical director, economic director, care director), and two respondents are from a city hospital (manager, medical director).
The research tool. The interview questions were formulated based on the literature in the field, the results obtained from previous research, as well as the observations gathered from the professional activity and work experience carried out in the hospital unit (research by action) by the authors of the research that work as physicians.
The interview grid was structured into three sections: the existence of a management system of ethics in the institution where the respondent works (preoccupations for ethics, priorities; the existence of the formal system of ethics management / an efficient and effective ethics programme in the institution where the respondent carries out the activity and what this system consists in; which methods and instruments are applied for the management of ethics; the extent of frequent confrontation with ethical dilemmas /conflicts of ethics in the activity done, and what type of dilemmas appear frequently, how the ethical dilemmas are solved when they appear during the activity, the reaction in these cases, which methods are applied, how to make decisions that have ethical implications, who deals with their solution (in case there are potential collaborations). The second section followed information/details regarding how operational/functional are several elements specific to the management of organizational ethics (specific ethics policies and procedures -including codes of ethics,, ethics committees, ethical culture, ethical leadership, ethics training programmes, systems of reporting the non-ethical behaviours, meetings and informative materials related to ethics, systems to monitor and penalize the non-ethical behaviours. The third section was dedicated to the classification of six elements specific to a an ethics programme (according to Muel Kaptein, 2015), based on the way the respondent managers consider that they should be applied in their institution (ethics line to report the non-ethical behaviours, policies to motivate the ethical behaviour, training programmes and communication on topics of ethics, ethics codes, policies of ethics accountability, ethics monitoring and audit). We specify that selecting only six of the nine elements analysed by Kaptein (2009) mentioned above is justified by the fact that in the Romanian hospitals there is no institution called ethics officer (this role is assumed by the Council of ethics): in the process of recruitment and selection the legal criteria are applied strictly and there are not used specific tests to assess the candidate"s ethics profile. Also, we considered the policies of accountability included in the sanctioning policies.
To each question on the interview grid, the participants received supplementary explanations and details regarding the ethics concepts, for their good understanding.
At the end of the interview, the respondents had the possibility to make openly comments/recommendations related to the system of ethics management in their institution.
In view of analysing the collected data, the responses were coded in categorical variables, according to the questions in the interview questionnaire.
The ethics of research. The study was approved by the ethics commission of the university that financed the research. Before completing the interview grid, the respondents received in written form the informed consent regarding the role and specifications of the academic research and their rights. The informed consent was signed by each participant and returned to the authors of the research.

Preoccupations for ethics in the institution
As for the responses to this question, it is noticed firstly the mentioning of values that refer to the employees (respecting their rights or moral obligations): "Respecting the employees' rights (two responses); "Promotion of ethics values among the medical, auxiliary and administrative staff" (legal attribution of the Council of ethics, two identical responses, manager and economic director, institute of psychiatry); "Promoting organizational ethics reflected in the employees" behavior" (two identical responses, medical director and care director, institute of psychiatry); "Protection of hospital against the danger of non-ethical behaviour: the managers should be a good example of ethics behaviour, the employees should be encouraged to act ethically, the employees should not accept small presents and comply with their duty" (economic director, municipal hospital); And for the patients: "Respecting the patients' rights, respecting the moral, deontological, professional principles in the hospital at any level or the medical/administrative structure, in view of raising the patients' degree of trust in the services offered" (medical director, hospital of chronic diseases); "Respect for the patient's autonomy" (manager, city hospital); "Assuring an ethic behaviour from the staff towards the patients and their visitors, the correct and transparent information" (manager, municipal hospital); "Staff's attitude toward the patients"; "Respecting the deontological and moral principles at the level of medical unit" (economic director, institute of oncology). June, 2018 Openings Volume 9, Issue 2 Also, it is underlined the importance of investing in the staff"s formation, as an important preoccupation in order to promote ethics in the organization, and a way to consolidate the quality of the medical service: "Priority: staff's formation in respect of correctly applying the ethic norms so that the equation Quality services = Ethic safety should be real" (medical director, hospital of chronic diseases).
Some responses address both categories of stakeholders, both employees and patients -"Informing patients and medical staff about the rights and obligations of each party" (medical director, municipal hospital).
Other responses to this question were less specific -"the quality of the medical service"… (medical director, municipal hospital); "Promoting respect, equity and responsibility instrumented by the commission of ethics, the ethic attitude in the medical act" (medical director, hospital of infectious diseases); "Lack of complaints and conflicts" (medical director, city hospital), "Value of transparency and probity in the activity, compliance to the specific laws, regulations, rules and policies" (care director, institute of oncology).
Some respondents limited their answer to mentioning organisms and their attributions (setting up, respectively stipulated by law) with role regulated to solve the problems of ethics: "According to the legislation, the commission of ethics was formed and functions" (manager, institute of oncology); "There is a commission of ethics that analyses and solves this kind of problems" (medical director of the hospital, institute of oncology); "There are regulations given by the commission of ethics, the priority and one of the attributions of the council of ethicsforum of moral authority formed…" (with the mention that the attributions of the council are according to Article 1, letter e) (director medical, city hospital; medical director, hospital of recovery); "The priorities of the Council of ethics are to identify, analyse and solve the discrepancies between the values, rights, and deontological and moral obligations appeared in the medical practice and in the relation between the patients and the medical staff" (manager, hospital of lung-physiology); "The patient's mechanism of feedback" (economic director, institute of oncology).

Existence of formal ethics management system/an efficient and effective ethics programme in the institution
Following the analysis of the responses, it is noticed that the system of ethics management is reduced by the respondents mainly to the activity of the Council of Ethics.
There are seven mentioned direct references to the existence and formal attributions of this institution set up by law.
"Yes, the Council of Ethics is formed and it functions" (manager, municipal hospital); "..., by the meetings of the council of ethics to solve the problems that appear" (economic director of the institute of oncology); "It is set up the Council of ethics, which analyses monthly the patients' feedback questionnaires, as well as the potential complaints from patients, employees" (medical director; manager, hospital of recovery); "There is a Council of ethics" (medical director, city hospital).
It has been also confirmed by other responses that equal the system of ethics management and the minimum imposed by law (based on the existence of some organisms with main role of monitoring): "There is, according to the legislation, and it is efficient" (manager, institute of oncology); "There is, it requires improvement" (medical director, institute of oncology); "This system is based on respecting the valid legislation" (manager, hospital of lung physiology).
The ethics commission were also mentioned three times ("there is a commission of ethics subordinated to the medical council" (medical director, hospital of infectious diseases); "At the Institute, the topic of ethics is managed by the Council of ethics and the Commission of ethics, each having distinct activity. The Council of ethics (analyses monthly the patients' feedback questionnaires, as well as the potential complaints from the patients and employees. The Commission for ethics manages the problems that appear at the Institute, each applying its own methodology, but having the same tool as base: the code of ethics" (medical director, institute of psychiatry).
Only one respondent gave a general response, but more comprising, nearing what means in essence the system of ethics management in the organization (still, without offering details): "There is currently in our institution a formal system of the ethics management , which consists in promoting ethic policies and the code of professional ethics, to guide the staff behaviour" (medical director, municipal hospital).
It is also noticed some critical opinions regarding the inefficient functioning of the system of ethics management: "There is a Council of ethics, there are procedures, and questionnaires of satisfaction, but the system is not efficient yet" (medical director, municipal hospital).
On the other hand, it is noticed a narrow understanding of the role of the Council of ethics: the fact that there are no formal complaints toward this forum is interpreted as being a proof that the system of ethics management functions very well: "At the moment, because of the existence of a Council of ethics with clear attributions, the content and mechanism of legal action, the management of ethics is active and not formal, the efficiency is due to the fact that there have been no complaints recorded at the Council of ethics" (medical director, hospital of chronic diseases). June, 2018 Openings Volume 9, Issue 2 Some respondents mentioned the systems and managerial tools of internal control: "The system of internal managerial control implemented... in 2015" (care director, institute of oncology); "The existence and implementation of the procedures for some processes" (manager of city hospital); "There is ROI, which comprises specific rules of ethical behaviour as well" (manager, municipal hospital).

Methods and tools applied
The responses given to this question show that the most common and frequently used tool applied in the ethics management in the hospital institutions where it was carried out our research is the feedback questionnaire (8 mentions in total), mainly the patient"s. Also, it was underlined the importance of the questionnaire regarding the employees" satisfaction (2 specific mentions): "Even though it is not a tool used by the Council of ethics, it is a tool analysed to obtain feedback from the employees, in view of improving the activity, including the aspects related to ethics and professional deontology" (economic director, institute of psychiatry).
Another instrument are the audiences (4 mentions), the electronic platform (mechanism of feedback for the patient) (2 mentions), code of ethics (2 mentions), register of suggestions and complaints (2 mentions): "The codes of ethics are applied, clear and comprising, on categories of staff, doctors, nurses, pharmacists, juridical counsellor, people who apply the preventive financial control" (economic director, municipal hospital).
To this question, also the procedures/activity specific to the Council of ethics were mentioned: "Respect of the legislation, namely the order of the Minister of Health to approve the content and attributions of the Council of ethics, which functions at the hospitals…" (manager, hospital of lung physiology); "... the work procedures of the Council of ethics, the analysis of the degree of satisfaction of the patients and employees -by questionnaires each semester -, the monthly analysis of the activity of the nucleus of quality, semester reports of the council of ethics to the medical council and committee director" (medical director, hospital of chronic diseases); "The analysis of the complaints regarding any incident of ethics from an employee/patient, any other person, and issuing decisions or orders to the Council of ethics, regular meetings of the Council of ethics, report of the activities, mechanism of patient's feedback" (care director, institute of oncology).
The respondents frequently used the term of commission, in generic sense, but as it results from the responses, the comments actually mentioned the activity of the Council of ethics: "Commission of ethics analyses all the cases and suggests solutions" (manager, institute of oncology); "The commission analyses all the complaints and makes suggestions; questionnaires, meetings where it is discussed the ethics in the existing protocols" (medical director, clinic hospital of infectious diseases); "The complaints related to ethical problems are solved by the commission of ethics" (medical director of hospital, institute of oncology); "After receiving the complaints, decisions or orders are issued" (economic director, institute of oncology) We also notice general responses related to taking into consideration some criteria of ethics in the managerial process: "Ethics landmarks in setting the objectives of the institutions"; "Consulting the employees in setting the objectives and decisions of the institutions"; "Using aspects of ethics in setting the criteria of performance"; "Promoting the code of ethics and professional behaviour" (medical director, municipal hospital); "Information of employees and patients, R.O.I., R.O.F., procedures, protocols, questionnaires applied to employees and patients, analysis" (manager, municipal hospital).
A respondent also mentioned other type of measures to consolidate the ethical behaviour: "Highlighting the ethical people monthly by posts on the notice board." There were also mentions to methods specific to respecting the ethics in the medical activity: using/obtaining the informed consent (3 comments), specific protocols and procedures implemented, standardized procedures to respect confidentiality: "The informed consent, standardized procedures to respect the confidentiality to obtain the informed consent" (manager, city hospital).

Facing ethical dilemmas in the activity carried out.
To this question, the most respondents answered that the ethical dilemmas are not at all frequent in their institution: "We have not really faced conflicts of professional ethics, and when they appeared, it was because of violating the moral or deontological principles by the medical staff, as well as the patients (medical director, municipal hospital)"; "They are not frequent, in most cases there are problems that appear between the staff members; of attitude toward the patient, to delimit the border-line responsibilities" (medical director, clinic hospital of infectious diseases); "Rarely, patients who require long-term hospitalization" (manager, city hospital), isolated cases. Especially those regarding the approval of clinical studies"; "To a low extent, in the area of service attributions, competences" (manager, municipal hospital); "It is not frequent; most of them are related to the employees' interpersonal relations"; "Conflicts between the teaching staff" (2 responses, manager and the medical director, hospital of recovery); "The frequency of the complaints at the hospital, is about 1 complaint/month" (2 responses, manager and medical director, institute of psychiatry). "In proportion of 90%, the incidents mentioned are not related to ethics, according to the decisions taken by the Council of ethics" (economic director, institute of June, 2018 Openings Volume 9, Issue 2 242 psychiatry); "Most of them are not ethical incidents or vulnerabilities, though" (medical director, institute of psychiatry); "Rare, unprincipled discussions among colleagues" (medical director, institute of oncology). Based on the responses, we notice that some respondents mistake the attributions of the Council of ethics with those of the commission of ethics (economic director, institute of oncology).
Other responses aimed at specific dilemmas in the clinic ethics: "Being a hospital of chronic diseases, with departments of oncology -palliative care, geriatrics -there are on several occasions, in front of the medical staff, ethical dilemmas: continuing the intensive treatment of some patient in terminal state/ state of irreversible deconditioning, the way of action when such a patient leaves the hospital, the way of communication family /patient in case of severe diagnostic" (medical director, hospital of chronic diseases).
More cutting responses are also noticed, highlighting the subfinancing of the medical system in Romania, which generates ethical dilemmas in the management of the institution, because this sub-financing has a negative impact on the quality of the medical service: "The income obtained from the medical services do not cover the optimum and necessary expenditure, they cannot satisfy all the requests of the quality medical service. These financial consequences lead to not assuring the conditions of comfort, which leads to conflict of ethics with the patients; not offering all the salary rights (increase at maximum level by the legal regulations); not purchasing the medical material -quality disinfectants (the criterion for purchase being always the lowest price)" (economic director, municipal hospital); "There are enough conflicts of ethics nature in the medical activity of the hospital, but very few reach the leaders' ears" (medical director, municipal hospital).

Solving the ethical dilemmas.
The responses offered to this question prove that in the respondents" opinion, solving the ethical dilemmas is mainly the task of Council of ethics (or the commission of ethics, term used generically by some of them), solution based on analysis, discussions and the communication of the decisions.
Thus, the role and procedures of this organism were mentioned seven times (specified by law): "The members of the Council of ethics meet and discuss the results of the questionnaires; the conflict is analysed in the Council of ethics, in the presence of both parties" (2 identical responses, medical director and the manager, hospital of recovery); "It is analysed in the Council of ethics, the result of the analysis is communicated to the patient and some measure is possibly applied" (medical director, municipal hospital); "Analysis in the Council of ethics, the commission for discipline; they try a mediation and solutions are found" (manager, municipal hospital).
Some responses were more detailed: "If at the Institute there is a complaint informing about a violation from the side of the staff, a violation of the patient's rights or any type of violation of the ethic norms, the Council of ethics has its own methodology that implies some steps... " (economic director, institute of psychiatry). "The Commission of ethics suggests solutions and they are applied by the manager and/or the managing committee." "We choose the variant that in our opinion is the least traumatic for the patient and relatives (manager, city hospital); "Solution by discussions and taking immediate measures, according to R.O.I"; "Applied methods -discussions, information with penalty, commission for discipline, contract termination"; "In the cases of ethical dilemmas mentioned above, the methods applied are deontological, humane, in agreement with the patient/family" (medical director, hospital of chronic diseases); "The commission of ethics suggests solutions and they are applied by the manager and/or the leading committee" (manager, institute of oncology); "We apply the decisions of the commission of ethics" (medical director, institute of oncology); "Decisions are issued, suggestions are made to solve the dilemmas according to OMS 145/2015 (economic director, institute of oncology); "Informing the person responsible for it, according to the procedures implemented" (care director, institute of oncology).
It is also noticed the mention on dilemmas more comprising, in the financial area, and the proof in this sense of some good managerial abilities from an economic director who understands the importance of team work and the major responsibility toward the patient: "I solve the ethical dilemmas related to the financial consequences by maximum economy, involvement of all the employees in the good management of the material and financial goods, asking for mutual understanding, kindness towards patients, which can compensate for the existing shortages" (economic director, municipal hospital). Other responses were very short: "Through dialogue"; "listening, analysis" (2 responses).

Making decisions with implications of ethics nature
Also when it comes to making decisions, the respondents consider that this process is the task of the Council of ethics (we notice 9 specific mentions of this organism): "The president of the Council of ethics calls for the meet of council, by means of the secretary, monthly and every time there are new complaints that require urgent analysis or the request of at least four of its members"; "Council of ethics"; "Commission for ethics"; "In the Council of ethics and the medical one; according to the legislation"; "By the Council of ethics";"By the vote of the members of the Commission June, 2018 Openings Volume 9, Issue 2 for ethics called by the manager's decision"; "By validation of the Council of ethics and informing the manager and the people involved (2 identical responses, manager and medical director, hospital of recovery); "Decisions are taken according to the existing protocol of palliative care/ nursing geriatric, which stipulates these situations and their solution (medical director, hospital of chronic diseases); "The Council of ethics analyses the incident of ethics, justifying documents are consulted, the involved parties are listening to, all the documents that could help define a point of view are asked, the legislation is consulted, and then the members of the Council of ethics make a decision after the secret vote, which they transmit further to the directors and which is finalized by making measures and formulating responses and solutions for those who made the complaints. The decisions are made after an analysis that consults the points of view of all the parties involved" (medical director, institute of psychiatry); "In the Council of ethics, the director committee" (economic director, municipal hospital); "After the analysis by the Council of ethics" (medical director, municipal hospital); "Based on the discussions with the people involved and the analysis in the Council of ethics, the commission of discipline (if necessary)" (manager, municipal hospital); "Commission of ethics, according to the valid legislation" (manager, institute of oncology); "In the Commission of ethics" (medical director, institute of oncology); "After the members' meeting, which takes place monthly, and whenever necessary, decisions are made" (economic director, institute of oncology); "Meetings at the Council of ethics, decisions whenever necessary" (care director, institute of oncology).

The official responsible for solving ethical dilemmas /collaborators
According the responses obtained, the Council of ethics (commission of ethics) is the main responsible with solving the ethical dilemmas: "At the hospital level, there is a council of ethics that analyses the complaints and suggests concrete measure as solution. The Council of ethics can request documents and information about the cause analysed, and can invite to its meetings people who can contribute to the solution of the issue presented; the members of the commission of ethics, chosen by vote" (medical director, municipal hospital); "Within the Council of ethics. Collaboration with the Medical Council"; "President of the Commission of ethics. There is a very good collaboration with the members of the Director Committee of the hospital" (manager, hospital of lung physiology); "Council of ethics and the lawyer of the unit" (medical director and manager, hospital of recovery); "Medical staff (doctors, nurses) employed, in collaboration with the patient /families. We do not have other collaborations" (medical director, hospital of chronic diseases).
"The institute solves its problems of this type by means of the Council of Ethics, represented by the President of the Council, the chiefs of the departments involved in collaboration with the syndicate..." (economic director, municipal hospital); "Members of the Council of ethics, possibly in collaboration with the Medical Council, the juridical department and the Director Committee" (medical director, municipal hospital); "Council of ethics, commission of discipline, collaboration with the Medical Council, director Committee, other commissions" (manager, municipal hospital); "Members of the commission of ethics, chosen by vote" (manager, institute of oncology); "Members of the Council of ethics, manager of the hospital" (economic director and care director, institute of oncology); "Commission of ethics" (medical director of the hospital, institute of oncology; medical director, clinic hospital of infectious diseases).

Existence and functioning of the specific managerial ethics elements in the institution
Ethics policies and procedures (including codes of ethics). All the respondents confirm these policies and procedures, in various forms or at various levels of functioning. Four respondents responded that they exist; others that they are respected (manager, hospital of lung physiology), they are "in work" (medical director, institute of oncology) or in course of setting (manager, institute of oncology), "updated, discussed, adopted (medical director, clinic hospital of infectious diseases). There were also indicated the codes of ethics / codes of ethics and professional deontology /codes of ethical conduct (9 mentions): "At hospital level, there are specific ethics operational procedures, including a professional code of ethics (medical director, municipal hospital); "The Code of ethical behaviour is distributed and promoted among employees, the staff is informed on the content, it respects the code regulations" (economic director and medical director, institute of psychiatry).
Some managers consider that the ethics policies are included implicitly in the "Annual strategic plan, Plan for improving the quality of medical services, Plan of specific measures to improve the medical services" (medical director, hospital of chronic diseases).
Also, it was mentioned the "Procedure to form and function the Council of ethics" (economic director and care director, institute of oncology).

Committees of ethics.
As for the existence of these organisms, we recorded 14 affirmative responses and 4 negative responses. There are also 5 mentions of the Council of ethic ("e.g., structure and content of the Council of ethics, approved by the manager" (economic director and medical care director, institute of oncology).
Other managers summarized that these committees are functional (manager, institute of oncology). Other respondents identified only the commission with responsibilities in ethics in the clinic research: "There is only one Commission of ethics at hospital level, the Committee of ethics is functional -for the June, 2018 Openings Volume 9, Issue 2 studies of medical research carried out at the clinic department and not only" (medical director, hospital of chronic diseases).
Ethical culture. In the opinion of 12 respondents, there is (or it requires improvement) an ethical culture in the hospital where they work, but other 7 respondents responded clearly that it does not exist. … "there is one, it requires improvement" (manager and medical director, institute of oncology); "very incipient" (medical director, hospital of infectious diseases); "education, transmitting ethical values, work principles and the warranty of some correct activities according to a moral behaviour are in the task of the section/department chief" (medical director, hospital of chronic diseases).
Some managers equalled the concept of ethical culture with the existence of the code of ethical behaviour and internal regulations (economic director and medical director, institute of psychiatry).

Ethical leadership.
A number of 16 respondents consider that it is promoted an ethical leadership in their institution (16 affirmative responses of Yes), but there were also given 3 negative responses. Some underlined: "Manager, rest of the members of the director committee, chiefs of departments, all are and must represent a model for all the employees in a hospital" (manager, hospital of lung physiology), "chiefs of organisation represent a model of ethic leadership" (medical director, hospital of chronic diseases). A respondent equalled ethical leadership and the existence of the Codes of ethics and professional deontology.
Ethics training programmes. The most respondents show that these programmes are not a practice in the organization, and accessible for all the employees -12 clear negative responses were provided in this sense. However, from the respondents answers, of those that confirm the existence of these programmes, we notice that they are not organized for all the employees, and their beneficiaries are the members of the Council of ethics (according to Art. 2 paragraph 8, "The members of the council of ethics benefit with priority from the formation in the field of ethics and integrity"): "Participation of the members of the Council of Ethics to specific courses -4 responses ("Programme of formation for the staff in the management of the medical unit in view of promoting the quality and integrity in the services offered in the medical system in the period 02-03.09.2015").
Other responses obtained were: "The study of the valid legislation made by the guard report, by the president of the Council of ethics at the hospital, by various courses of professional training" (manager, hospital of lung physiology); "psychological counselling for the staff (with psychologist), in the medical ethics competencies" (medical director, clinic hospital of infectious diseases). Other responses show an informal preoccupation in the institution for this aspect -"rather coaching". Some managers admit that the "participation to such training programmes, in hospitals or outside them, is useful" (medical director, hospital of chronic diseases), but they do not mention whether these are a practice or not in their institution. Unethical behaviour reporting system. Most respondents (18 of them) confirm the existence of the systems of report, to a lower or higher extent. Thus, we obtained 7 general responses of "yes" or the type "there is, in all the ways mentioned"; "all the above"; "all". They mentioned the audiences (4 mentions), email -3 responses ("by accessing the existing email address on the site of the hospital), by direct address at secretariat manager, boxes for complaints and observations, the commission for discipline, complaints registered" (2 identical responses at the same hospital). Some responses prove that the system of report is comprising: "Council of ethics, complaints -online version, published, register of suggestions and complaints, satisfaction questionnaires (staff and patients), electronic platform, department of integrity for the ministry of health where there are regular reports, the report made to DSP" (Direction of Public Health) (economic director, institute of psychiatry). Only one response was negative.
Meetings and informative materials related to ethics (flyers, notes, audio-video materials, etc.): Yes (6 responses), No (5 responses); "Yes, to a small extent" (3 responses); "notes"; … meetings on this topic during the monthly meetings of the members of the hospital Council of ethics; flyers for patients and staff" (medical director, hospital of chronic diseases); "Questionnaires on categories of staff, and questionnaires for patients" (economic director, municipal hospital).
We also noticed different views regarding what happens in the organization: at the same hospital (institute of oncology) the manager and medical director consider that there are no meetings and informative materials on matters related to ethics, but the economic director and the care director consider that they are.
Systems for monitoring and punishing the unethical behaviour. "Yes/there is" (8 responses); "Electronic platform" (4 responses); "No" (2 responses); "Commission of ethics of the hospital" (2 responses); ); "…a series of measures on some people who proved non-ethical behaviour by decisions/orders" (manager, hospital of lung physiology); "Papers, explicative notes, setting measures of remedy in the director council" (economic director, municipal hospital "commission of active discipline" (medical director, hospital of chronic diseases). Other systems of monitoring mentioned were: "analysis of the questionnaires, complaints, decisions of the Council of ethics"; "managing the database of questionnaires and complaints." In the second part of the interview, the respondents were invited to classify the elements of an ethics programme (after Muel Kaptein"s research (Kaptein, 2015;Kaptein, 2009), according the importance in implementing: 18 respondents classified on the first place the ethics training programmes, codes of ethics and policies of monitoring and audit. On the second place, equally, were placed the policies of motivation, the policies of accountability and the reporting lines. A respondent did not order completely the list of elements.

Discussion
Our study underlines the fact that the management of ethics in the hospitals in Romania is strongly instrumentalized, limited to the applying methods and tools that respond to the legal requirements for the healthcare sector activity, and being reduced to the activity of the institution set by law -Council of ethics. It was the leitmotif of the responses to the questions related to the evaluation of the ethics management included in the research carried out. The conclusion of the research is that the staff with managerial attributions considers is in majority as being the actor/main responsible that must take over as their task the preoccupation for ethics, solving the ethical dilemmas and making decisions of ethics nature. Unfortunately, the concept of ethical culture is associated with its activity, and the respondents consider that it is sufficient if only the members of the council participate in the ethics training programmes. Ethics seems to be the responsibility of an "employee" or a specific organism, not an implicit task of all. At the same time we notice that the lack of specific training in ethics management leads to a narrow understanding and approach of the importance and application of the concept.
Management of ethics is a field that requires clearly improvementall the employees need specific ethics training to understand what means a desirable ethical behaviour at the work place, which are the organizational expectations in this sense, how to solve an ethical dilemma, how to make an ethical decision correctly, on taking into account the specific of the activity of each professional category and the mission and legitimate objectives of the organization where they live. The managers of the organization must be aware that the management of ethics is a sub-system together with the other functional areas that must be supported by organisational ethics policies and procedures, an alive ethical culture, a strong ethical leadership, adequate motivational systems and rewarding. The employees must receive and understand the message that ethics is a daily problem for everybody, and all must take into account the ethics principles in any moment in the activity carried out, that the ethical dilemmas do not solve only by means of the council of ethics, but they can appear at anyone, and the ethical decision is also everybody"s responsibility. The council of ethics is only a tool in this whole, and its existence is not enough to assure the ethical behaviour.
We notice that in some hospitals the responses were patterned, and the staff who participated in the research gave the same standardized response. In other hospital units, we notice differences of perception, different views in respect of the existence/functioning in practice of some elements. Other managers preferred not to give a complete answer, which makes us wonder how important this subject is in their activity.
Nevertheless, two managers mentioned the necessity of setting also policies to stimulate the ethical behaviour: "Setting up a code of ethics and implementing some policies to motivate the ethical behaviour together with training programmes and communication on ethics topics" (medical director, institute of oncology); "Courses of formation"; "policies to motivate the ethical behaviour" (medical director, city hospital).
Comments to the open questions illustrates the awareness to the need of the specific managerial ethics tools, an open vision to ethics, especially in the small hospitals: "Formation of specialists in ethics with the task of moral counselling in hospitals, of which both doctors and the staff of the medical institution should benefit, as well as patients and relatives, to counsel the patients who must make an important decision from the medical point of view. By developing complementary tools, the Council of ethics that the employees should support when they need to make decisions, to help the doctors make correct decisions for their patients, which would allow the patients and their relatives to understand the doctors' decisions. Setting some internal information meant to make the doctors and the other employees aware of the fact that, for example, the foul language, even in the intimacy of the changing rooms, is immoral, not only inadequate" (economic director, municipal hospital).
We also notice the awareness of the respondents on the importance and need to implement an ethics management system: "It is necessary to be aware of the importance of the ethics system and the establishment of a rigorous management for it" (medical director, municipal hospital); "It is good, the start has been done. Satisfactory results, there is some involvement; the main factor is the human factor, and the system of values of each person." June, 2018 Openings Volume 9, Issue 2

Conclusions
Following our study, we find that the ethics management system in Romanian hospitals still needs efforts to gain its place in their strategic management model and development direction. The starting point should be the understanding of the constitutive values that are at the fundament of the organisational mission and further on of the operational values that are "correlated with the policies of the organisation, its products and services" and "around which are set the organisation" good practices" (Sandu & Caras (Frunză), 2014: 847). The organisational values, vision and mission need to be supported in practice by "a backbone", a structure, in other words by an effective and efficient organisational ethics system.
We suggest that an useful approach to this system might be from the perspective of the "supervision of ethics" model proposed by Caras (Frunză) and Sandu as being "a particular form of ethical expertise" (2014: 151). It requires the existence of a "supervisor of ethics" who has to take on a key role, "to facilitate the relations between the organization, the professional and the client" (Caras (Frunză) &Sandu, 2014: 145). The model has multiple functions (see p. 148), complements the functions of other ethics support bodies (ethics committees, ethics audit ...), and addresses professionals with responsibilities to make ethical decisions in their activity, responds to "their needs for counselling, assessment and support, fit to the ethical norms of their profession" (Caras (Frunză) & Sandu, 2014: 145).
The medical personnel and decision-makers should be made aware of the importance and role of the ethics management system within the hospital unit's mission, to understand the functioning of its components and mechanisms, be permanently trained and advised to use it in the exercise of their profession to the benefit of all stakeholders.