Building a Preventive Ethics Program

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Building a Preventive Ethics Program
Mary Beth Foglia RN PhD MA IntegratedEthics
Manager Preventive Ethics, and Senior Staff,
Ethics Evaluation Group National Center for
Ethics in Health Care (VHA)
Catholic Health East August 5, 2009
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Learning objectives

• Describe IntegratedEthics model
• Identify key elements of Preventive Ethics
• Describe how to get started in developing a
  preventive ethics approach

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What Is IntegratedEthics?

• A national education and organizational change
  initiative
• A comprehensive, systematic approach to ethics in
  health care

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Perceived Quality Gaps

• Lack of adequate training 96
• Lack of a systematic approach 88
• Ethics program not well integrated 80
• Ethics program lacks standards 71
• Ethics program not improvement-oriented 68
• Ethics program too narrowly focused 64
• Ethics program not data-driven 64
• Lack of leadership support/accountability 60

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The IntegratedEthics Model
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What Is Ethics Quality?

• Decisionsand actions

Systemsand processes
Environmentand culture
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Three Core Functions

• Ethics Consultation
• Responding to ethics questions in health care
• The CASES Approach
• Preventive Ethics
• Addressing ethics quality gaps on a systems level
• The ISSUES Approach
• Ethical Leadership
• Fostering an ethical environment and culture
• The Four Compass points

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Three Core Functions

• Ethics Consultation

Preventive Ethics
Ethical Leadership
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Domains of ethics in health care

• Shared decision making with patients
• Ethical practices in end-of-life care
• Patient privacy and confidentiality
• Professionalism in patient care
• Ethical practices in resource allocation

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Domains of ethics continued

• Ethical practices in business and management
• Ethical practices in government service
• Ethical practices in research
• Ethical practices in the everyday workplace
• IntegratedEthics program

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Introduction to Preventive Ethics
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Preventive ethics defined
Activities performed by an individual or group on
behalf of a health care organization to identify,
prioritize, and address systemic ethics issues
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Goal of Preventive Ethics

• Produce measurable and sustainable improvements
  in an organizations ethics practices

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What is an Ethics Quality Gap?

• Difference between best practice and current
  practice
• Difference between what staff ought to do and
  what staff is doing

Preventive ethics seeks to reduce gaps through a
quality improvement approach
Preventive ethics (PE) seeks to reduce gaps
through a quality improvement approach
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Preventive Ethics Reduces Variation in Ethics
Practices
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PE Promotes Organizational Justice

• Treat equals equally and unequals unequally

From Aristotle, Nicomachean Ethics. translated
by Weldon, J.E.C. Prometheus Books (Buffalo,
NY1987).
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Key assumptions of preventive ethics

• Traditional case-based ethics consultation
  services dont address systems-level obstacles to
  ethical practices
• Developing individual virtue through training and
  education alone cant ensure ethical practice

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Key assumptions of Preventive Ethics continued

• The primary causes of ethics quality gaps lie in
  organizational systems and processesnot the
  behavior of individuals
• Ethical practices in health care can be measured
  and improved

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Introduction to ISSUES
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ISSUES approach to reducing ethics quality gaps

• Identify an issue
• Study the issue
• Select a strategy
• Undertake a plan
• Evaluate and adjust
• Sustain and spread

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ISSUES approach to reducing ethics quality gaps
overview

• A systematic, step-by-step process to narrow the
  gap between best practice and current
  practice
• Marries principles and methods of quality
  improvement with principles and methods of
  ethical analysis
• Targets the systems and processes that influence
  ethical practices in a facility

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Crosswalk ISSUES and FOCUS-PDSA
ISSUES FOCUS-PDSA
Identify an issue Find an opportunity for
improvement (Core team ad hoc members) Organize
a team Study the issue Clarify processes and
problems Select a strategy Understand root
causes Select a strategy Select
improvement Undertake a plan Plan Undertake a
plan Do Evaluate and adjust Study Sustain and
spread Act
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Indications for PE Examples from the Field
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Shared Decision Making

• Examples
• Advance directives of dialysis patients are not
  accurate, or updated
• Advance care planning is not addressed in primary
  care
• Advance care planning processes do not include
  elicitation of mental health treatment
  preferences
• Electronic informed consent is not utilized
• Gurney consent is obtained for non-emergent
  cases
• Organ donation screening practices are
  inconsistent with policy

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Professionalism

• Examples
• Patients discharged AMA are denied follow-up
  appointments, discharge medicines and discharge
  instructions
• Adverse events are not consistently reported,
  disclosed or documented in the health record

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Resource Allocation

• Examples
• Practice of Discharge by noon results in
  avoidable readmissions, burdensome rework, and
  patient dissatisfaction
• TCU patients requiring/requesting palliative care
  are transferred to ED and then to inpatient care
• The process for referring Veterans for services
  outside of VHA is inconsistent and perceived to
  be arbitrary and unfair
• Care processes for difficult patients are
  inconsistent and lack coordination

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End-of-Life

• Examples
• Process to address requests for portable Do Not
  Attempt Resuscitation (DNAR) orders is lacking
• Processes for eliciting patient preferences and
  goals of care are inconsistent resulting in
  futile care
• Attending physicians routinely disapprove
  requests for ethics and palliative care consults
• Clinical warnings (CWAD) are inconsistently
  updated leading to staff mistrust of DNAR status

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Everyday Workplace

• Examples
• Inconsistencies exist in emergency-related
  facility closures/time and leave policies across
  VISN causing staff and labor partners moral
  distress (unfair and arbitrary)

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Privacy and Confidentiality

• Examples
• Food service workers note that personal food
  items (food brought in for patients by
  family/friends) are labeled with full name, DOB
  and social security number

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Select Outcomes
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Select Outcomes
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Select Outcomes
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Select Outcomes
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Select Outcomes
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Getting Started
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Models of Organizing PE

• Core function of IntegratedEthics program
• Reports to facility leadership through the
  IntegratedEthics facility council
• Part of Ethics Program
• Subcommittee of organizational ethics with strong
  linkages to ethics consultation
• Part of Quality Management Program

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Assembling your team Get the Right People

• Core members
• PE coordinator with dedicated time
• Team members
• Responsible for ongoing work of PE function

• Ad hoc members
• Issue specific
• Time-limited commitment
• Most often content or process experts and owners

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Proficiencies required to perform PE

• Quality improvement principles, methods, and
  practices
• Numeric or statistical (basic) literacy
• Working knowledge of health care delivery
  system systems thinking
• Knowledge of routine data sources to identify
  ethics quality gaps and baseline measures
• Ability to use or develop data tracking tools

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Proficiencies continued

• Practical grasp of how to promote sustained
  organizational change
• Knowledge of common ethics topics and concepts
• Skill in moral reasoning

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IE Performance Measures Preventive Ethics

• Measure of Success FY10
• Preventive Ethics
• Each facility, with input from the IE Council,
  will complete a minimum of 2 preventive ethics QI
  cycles
• Each Network will address at least one Network
  wide cross-cutting issue identified through IE
  resources (e.g., Facility Workbooks, IE Staff
  Survey, QI logs, ECWeb reports, recurrent cases)

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Award Programs/Leadership Mandates

• Prioritize high priority and cross cutting ethics
  quality gaps
• Teams chartered to address ethics quality gap
• Disseminate results to foster an organizational
  learning environment

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Contact Us

• www.ethics.va.gov
• Download publicly available materials
• Mary Beth Foglia
• Preventive Ethics Manager
• marybeth.foglia_at_va.gov
• [phone]

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Questions?