Ethics Consultation: Responding to Ethics Questions in Health Care - U

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Improving Ethics Quality in Health Care Improving Ethics Quality in Health Care Ethics Consultation Responding to Ethics Questions in Health Care Authors Ellen Fox, MD Director National Center for Ethics in Health Care Veterans Health Administration (VHA) Kenneth A. Berkowitz, MD Ethics Consultation Chief National Center for Ethics in Health Care Barbara L. Chanko, RN, MBA Ethics Consultation Staff National Center for Ethics in Health Care Tia Powell, MD Executive Director, New York State Task Force on Life and the Law (Formerly ethics consultation staff, National Center for Ethics in Health Care) Acknowledgments The authors wish to extend special thanks to Bette Crigger, Mary Beth Foglia, and other colleagues in the National Center for Ethics in Health Care and to the following individuals for their critical review and thoughtful input: VHA Reviewers James Adams, Nancy Allen, Jane Altemose, Paul Bauck, Vern Bensching, Stephanie Berkson, Neena Biswas, Donna Clar, Mark Enderle, Gwen Gillespie, Steven Hardin, Phillip Kleespies, Jack Klugh, Robert Kolodner, Douglas Lanska, Sathya Maheswaran, Claire Maklan, Susan Marklin, Jimmy Moore, Richard Mularski, Dena Neihaus, Jeffrey Oak, Thomas Phillips, Peter Poon, Terry Sparks, Victoria Timpa, Shirley Toth, Lad Vidergar, Stephen Wear, and members of VHA 9s National Ethics Committee External Reviewers ... more. less.

George Agich, Mark Aulisio, Robert Baker, Peggy Connolly, Arthur Derse, Nancy Dubler, Denis Duchesne, Albert Dzur, Linda Farber Post, Judi Beckman Friedson, David Kozishek, Bill Kubat, Ronald Miller, John Moskop, William Nelson, James Peterman, Lawrence Schneiderman, Jeffrey Spike, Jennifer Stempel, Rebecca Stoeckle, and Robert Truog Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii Part I Introduction to IntegratedEthics IntegratedEthics: Improving Ethics Quality in Health Care. . . . . . . . . 1 Part II Introduction to Ethics Consultation in Health Care What Is Ethics Consultation in Health Care?. . . . . . . . . . . . . . . 13 What Models May Be Used to Perform Ethics Consultation? . . . . . . 14 What Proficiencies Are Required to Perform Ethics Consultation? . . . 16 What Are the Critical Success Factors for Ethics Consultation?. . . . . 18 Part III CASES: A Step 3by 3Step Approach to Ethics Consultation Using the CASES Approach . . . . . . . . . . . . . . . . . . . . . . . 26 Step 1: C larify the Consultation Request. . . . . . . . . . . . . . . . . 27 Step 2: A ssemble the Relevant Information . . . . . . . . . . . . . . . 32 Step 3: S ynthesize the Information . . . . . . . . . . . . . . . . . . . 38 Step 4: E xplain the Synthesis . . . . . . . . . . . . . . . . . . . . . . 44 Step 5: S upport the Consultation Process. . . . . . . . . . . . . . . . 47 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 IntegratedEthics Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 This document and other IntegratedEthics materials are available online through the website of the National Center for Ethics in Health Care. VA employees should access the site via intranet at vaww.ethics.va.gov/IntegratedEthics. Others should access the site via the Internet at www.ethics.va.gov/IntegratedEthics . ii Executive Summary ii Executive Summary Ethics Consultation: Responding to Ethics Questions in Health Care e stablishes VA guidance for health care ethics consultation, one of the three core functions of IntegratedEthics. It was designed as a primer, to be read initially in its entirety by everyone who participates in ethics consultation, including leaders responsible for overseeing the ethics consultation function. Subsequently, it can serve as a useful reference document when consultants wish to refresh their memories or to answer specific questions. Part I: IntegratedEthics 4Improving Ethics Quality in Health Care Part I of the primer provides an overview of IntegratedEthics, describing the need for IntegratedEthics and how the IntegratedEthics model addresses that need. Readers who have not already read this overview are encouraged to do so to understand how ethics consultation fits within the broader IntegratedEthics program. Part II: Introduction to Ethics Consultation in Health Care Part II provides an overview of health care ethics consultation, outlines the proficiencies required to perform ethics consultation, and reviews other factors necessary for success: What is ethics consultation in health care? For the purposes of this document, we define ethics consultation in health care as a service provided by an individual ethics consultant, ethics consultation team, or ethics committee to help patients, providers, and other parties resolve ethical concerns in a health care setting. The overall goal of ethics consultation is to improve health care quality by facilitating the resolution of ethical concerns . By providing a forum for discussion and methods for careful analysis, effective ethics consultation: promotes practices consistent with high ethical standards helps foster consensus and resolve conflict in an atmosphere of respect honors participants 9 authority and values in the decision-making process educates participants to handle current and future ethical concerns Models for performing ethics consultation Ethics consultation may be performed by an individual ethics consultant, an ethics committee, or an ethics consultation team. A consultation service should use all three models, determining on a consultation-by-consultation basis which model is most suitable in the particular circumstances. Proficiencies required for ethics consultation Effective ethics consultation requires a range of skills and specific proficiencies. IntegratedEthics adapts the ccore competencies d recommended by the American Society for Bioethics and Humanities (ASBH) to identify required proficiencies for ethics consultants: knowledge, including familiarity with moral theory and bioethics concepts, health care practices, and organizational mission and policy skills, including ability to carry out ethical analysis, communicate effectively, and build consensus character traits, including tolerance, honesty, prudence, integrity, and courage iii Executive Summary iii Critical success factors for ethics consultation To provide an effective mechanism for addressing ethical concerns in health care, an ethics consultation service must have integration, leadership support, expertise, staff time , and resources. Access, accountability, organizational learning , and evaluation are additional factors that should be ensured. Because all these factors are critical for the success of ethics consultation services, each should be addressed in policy . Part III: CASES 4A Step-by-Step Approach to Ethics Consultation Finally, Part III describes in detail a practical, systematic process for performing ethics consultations pertaining to active clinical cases. CASES: A step-by-step approach to ethics consultation The National Center for Ethics in Health Care designed the CASES approach to standardize the process of ethics consultation throughout the VA system. For consultations involving active clinical cases, consultants should follow all the steps in the CASES approach. For other types of consultations, such as general questions about ethics, policy interpretations, or requests for ethical analysis of organizational ethics topics, the CASES approach should be modified as needed. The CASES steps were initially designed to guide ethics consultants through the complex process needed to effectively resolve ethical concerns in active clinical cases. We intend these steps to be used similarly to the way clinicians use a standard format for taking a patient 9s history, performing a physical exam, or writing up a clinical note. Even when some steps don 9t require specific, observable action, each step should be considered systematically as part of every ethics consultation. Tools for ethics consultation The IntegratedEthics initiative emphasizes distance learning, providing print, video, and electronic media to help ethics consultation services succeed. Practical tools to assess consultants 9 proficiency for performing ethics consultation, obtain feedback from staff who participate in ethics consultation, remind consultants of the steps in the CASES approach, and appropriately document ethics consultation activities are available on the Center 9s website, vaww.ethics.va.gov/IntegratedEthics or www.ethics. va.gov/IntegratedEthics . The CASES Approach C larify the consultation request Characterize the type of consultation request Obtain preliminary information from the requester Establish realistic expectations about the consultation process Formulate the ethics question A ssemble the relevant information Consider the types of information needed Identify the appropriate sources of information Gather information systematically from each source Summarize the consultation and the ethics question S ynthesize the information Determine whether a formal meeting is needed Engage in ethical analysis Identify the ethically appropriate decision maker Facilitate moral deliberation among ethically justifable options E xplain the synthesis Communicate the synthesis to key participants Provide additional resources Document the consultation in the health record Document the consultation in consultation service records S upport the consultation process Follow up with participants Evaluate the consultation Adjust the consultation process Identify underlying systems issues The CASES Approach C larify the consultation request Characterize the type of consultation request Obtain preliminary information from the requester Establish realistic expectations about the consultation process Formulate the ethics question A ssemble the relevant information Consider the types of information needed Identify the appropriate sources of information Gather information systematically from each source Summarize the consultation and the ethics question S ynthesize the information Determine whether a formal meeting is needed Engage in ethical analysis Identify the ethically appropriate decision maker Facilitate moral deliberation among ethically justifable options E xplain the synthesis Communicate the synthesis to key participants Provide additional resources Document the consultation in the health record Document the consultation in consultation service records S upport the consultation process Follow up with participants Evaluate the consultation Adjust the consultation process Identify underlying systems issues \x3 Part I: Introduction to IntegratedEthics Part \x3 Introduction to IntegratedEthics IntegratedEthics: Improving Ethics Quality in Health Care VA: A Leader in Quality and Organizational Change VA has become the standard-bearer for quality in American health care. VA consistently outperforms other health care organizations on a wide range of quality measures.[1,2] Publications from The New York Times and The Washington Post to Business Week and Washington Monthly laud VA for providing cthe best care anywhere, d[3 36] and today 9s VA makes headlines for outranking private health care organizations in customer satisfaction.[4,5] The Agency has been equally lauded as a cbright star d in patient safety.[7] And VA 9s electronic health record system has earned it Harvard University 9s prestigious cInnovations in American Government d award.[8] How did an enormous, public health care system with finite resources take the lead in quality? VA 9s impressive examples of excellence have resulted from the work of visionary leaders and dedicated staff deliberately creating organizational change. Each organizational change initiative was innovative and established a new national standard that was subsequently adopted by other organizations. Each was based on a recognized need and supported by top leadership. Each was carefully designed and field-tested before being implemented on a national scale. Each involved centrally standardized systems interventions that affected staff at all levels. Each was supported by practical tools and education for staff. And each required not only significant shifts in thinking on the part of individuals, but also significant changes in organizational culture. As the largest integrated health care system in the United States and a recognized leader in quality and organizational change, VA is now poised to take on a new challenge: to disseminate a systems-focused model to promote and improve ethical practices in health care 4and a new way of thinking about ethics. Why Ethics Matters Throughout our health care system, VA patients and staff face difficult and potentially life- altering decisions every day 4whether it be in clinics, in cubicles, or in council meetings. In the day-to-day business of health care, uncertainty or conflicts about values 4that is, ethical concerns 4inevitably arise. Responding effectively to ethical concerns is essential for both individuals and organizations. When ethical concerns aren 9t resolved, the result can be errors or unnecessary and potentially costly decisions that can be bad for patients, staff, the organization, and society at large.[9 312] When employees perceive that they have no place to bring their ethical concerns, this can result in moral distress, a recognized factor in professional cburnout, d which is a major cause of turnover, especially among nurses.[13] \x4 Part I: Introduction to IntegratedEthics A healthy ethical environment and culture doesn 9t just improve employee morale; it also helps to enhance productivity and improve efficiency.[14 316] Organizations that support doing the right thing, doing it well, and doing it for the right reasons tend to outperform other organizations in terms of such measures as customer satisfaction and employee retention.[17,18] Failure to maintain an effective ethics program can seriously jeopardize an organization 9s reputation, its bottom line, and even its survival.[19] Ethics is also closely related to quality. A health care provider who fails to meet established ethical norms and standards is not delivering high-quality health care. By the same token, failure to meet minimum quality standards raises ethical concerns. Thus ethics and quality care can never truly be separated. The Concept of Ethics Quality When most people think of quality in health care, they think of technical quality (e.g., clinical indicators) and service quality (e.g., patient satisfaction scores). But ethics quality is equally important.[20] Ethics quality means that practices throughout an organization are consistent with widely accepted ethical standards, norms, or expectations for a health care organization and its staff 4set out in organizational mission and values statements, codes of ethics, professional guidelines, consensus statements and position papers, and public and institutional policies. For example, let 9s say a patient undergoes a surgical procedure. From a technical quality perspective, the operation was perfectly executed, and from a service quality perspective, the patient was perfectly satisfied with the care he received. So the care was of high quality, right? Well, not necessarily. Imagine that the patient was never really informed 4or was even misinformed 4about the procedure he received. This would indicate a problem with ethics quality. The idea of ethics quality as a component of health care quality isn 9t exactly new. Donabedian, who is widely regarded as the father of quality measurement in health care, defined quality to include both technical and interpersonal components, interpersonal quality being defined as cconformity to legitimate patient expectations and to social and professional norms. d[21] Other experts have proposed cethicality d 4the degree to which clinical practices conform to established ethics standards 4as an important element of health care quality.[22] And it 9s been argued that specific performance measures for ethics should be routinely included in health care quality assessments.[20] Ethics Quality Gaps Health care organizations in this country have significant copportunities for improvement d with respect to ethics quality,[23] and VA is no exception. Over the past several years, VA 9s National Center for Ethics in Health Care has been collecting data on the VA health care system 4through formal and informal surveys, interviews, and focus groups 4to understand where there are ethics quality gaps. What have we found? VA employees: regularly experience ethical concerns want more tools and support to address their concerns perceive that the organization doesn 9t always treat ethics as a priority Part I: Introduction to IntegratedEthics Ethics committees or programs: are seldom described as influential or well respected tend to focus narrowly on clinical ethics and fail to address the full range of ethical concerns in the organization operate as silos in relative isolation from other programs that deal with ethical concerns tend to be reactive and case oriented, instead of proactive and systems oriented often lack resources, expertise, and leadership support do not consistently follow specific quality standards are rarely evaluated or held accountable for their performance In addition, VA leaders recently got a wake-up call when an independent audit found material weaknesses in accounting practices and suggested problems with cethics d and cculture d as a root cause.[18] The audit found evidence that at least in some instances, cmaking the numbers d seemed to be valued more than ethics. Ironically, the very things that have made VA a leader in quality may actually put the organization at risk from an ethics perspective. VA 9s keen focus on performance excellence in the clinical and financial arenas, through use of powerful performance measurement and rewards systems, may unintentionally have supported a culture in which cgetting to green d is all that counts. Findings from VA 9s all-employee survey reveal other opportunities for improvement in ethical environment and culture. High scores in the area of cbureaucratic d culture indicate that the organization emphasizes rules and enforcement.[24] Rules usually define prohibited behavior or minimal standards, instead of inspiring exemplary or even good practices. A rules-based culture tends to emphasize compliance with cthe letter of the law d as opposed to fulfilling cthe spirit of the law. d From an ethics perspective, overemphasizing rules can lead to cmoral mediocrity d[25] 4or worse, unethical practices, if employees equate cno rule d with cno problem d or if they cgame the rules d by developing ethically problematic workarounds.[26] While employees in rules-driven organizations tend to concentrate on what they must do, those in organizations with a healthy ethical environment and culture tend to concentrate more on what they should do 4finding ethically optimal ways to interpret and act on the rules in service of the organization 9s mission and values. Thus while VA is a leader in quality, historically, the organization hasn 9t placed a great deal of emphasis on ethics quality. To achieve a truly cbalanced scorecard, d VA needs to systematically prioritize, promote, measure, and reward ethical aspects of performance. IntegratedEthics is the mechanism by which VA will achieve this goal 4ensuring that ethics quality is valued every bit as much as other organizational imperatives, such as cmaking the numbers d and cfollowing the rules. d IntegratedEthics VA has recognized the need to establish a national, standardized, comprehensive, systematic, integrated approach to ethics in health care 4and IntegratedEthics was designed to meet that need. This innovative national education and organizational change initiative is based on established criteria for performance excellence in health care organizations,[27] methods of continuous quality improvement,[28] and proven strategies Part I: Introduction to IntegratedEthics for organizational change.[29] It was developed by VA 9s National Center for Ethics in Health Care with extensive input from leaders and staff in VA Central Office and the field, expert panels and advisory groups, and reviewers within and outside the organization. Materials developed for IntegratedEthics underwent validity testing, field testing, and a 12-month demonstration project in 25 facilities. Now, the expectation is that every VA health care facility will implement the IntegratedEthics model to ensure ethics quality in health care. Levels of Ethics Quality Ethics quality is the product of the interplay of factors at three levels: decisions and actions, systems and processes, and environment and culture. The image of an iceberg helps to illustrate the concept of ethics quality in health care: At the surface of the cethics iceberg d lie easily observable decisions and actions, and the events that follow from them, in the everyday practices of a health care organization and its staff. Beneath that, however, organizational systems and processes drive decision making. Not immediately visible in themselves, these organizational factors become apparent when we look for them 4 for example, when we examine patterns and trends in requests for ethics consultation. Deeper still lie the organization 9s ethical environment and culture, which powerfully, but nearly imperceptibly shape its ethical practices overall. This deepest level of organizational values, understandings, assumptions, habits, and unspoken messages 4what people in the organization know but rarely make explicit 4is critically important since it is the foundation for everything else. Yet because it 9s only revealed through deliberate and careful exploration, it is often overlooked. Together, these three levels 4decisions and actions, systems and processes, and environment and culture 4define the ethics quality of a health care organization. Many ethics programs make the mistake of spending too much time in a reactive mode, focusing only on the most visible of ethical concerns (i.e., the ctip of the iceberg d). But to have a lasting impact on ethics quality, ethics programs must do more: They must continually probe beneath the surface to identify and address the deeper organizational factors that influence observable practices. Only then will ethics programs be successful in improving ethics quality organization-wide. IntegratedEthics targets all three levels of ethics quality through its three core functions, discussed in detail below: ethics consultation, which targets ethics quality at the level of decisions and actions; preventive ethics, which targets the level of systems and processes; and ethical leadership, which targets the level of environment and culture. Domains of Ethics in Health Care Just as IntegratedEthics addresses all three levels of ethics quality, it also deals with the full Decisions & actions Systems & processes Environment & culture Image courtesy of Uwe Kills. Used with permission. Decisions & actions Systems & processes Environment & culture Image courtesy of Uwe Kills. Used with permission. \x7 Part I: Introduction to IntegratedEthics range of ethical concerns that commonly arise in VA, as captured in the following content domains: Shared decision making with patients (how well the facility promotes collaborative decision making between clinicians and patients) Ethical practices in end-of-life care (how well the facility addresses ethical aspects of caring for patients near the end of life) Patient privacy and confidentiality (how well the facility protects patient privacy and confidentiality) Professionalism in patient care (how well the facility fosters behavior appropriate for health care professionals) Ethical practices in resource allocation (how well the facility demonstrates fairness in allocating resources across programs, services, and patients) Ethical practices in business and management (how well the facility promotes high ethical standards in its business and management practices) Ethical practices in government service (how well the facility fosters behavior appropriate for government employees) Ethical practices in research (how well the facility ensures that its employees follow ethical standards that apply to research practices) Ethical practices in the everyday workplace (how well the facility supports ethical behavior in everyday interactions in the workplace) In many health care organizations, ethics programs focus primarily (or even exclusively) on the clinical ethics domains, leaving nonclinical concerns largely unaddressed. Another common model is that ethical concerns are handled through a patchwork of discrete programs. In VA facilities, clinical ethics concerns typically fall within the purview of ethics committees, while concerns about research ethics typically go to the attention of the institutional review board, and business ethics and management ethics concerns usually go to compliance officers and human resources staff. These individuals and groups tend to operate in relative isolation from one another and don 9t always communicate across programs to identify and address crosscutting concerns or recurring problems. Moreover, staff in these programs may not be well equipped to bring an ethics perspective to their areas of expertise. For example, when employees experience problems relating to their interactions with persons of a different ethnicity or cultural background, this is often treated as an EEO issue. But resolving the situation might require not just a limited EEO intervention but a more systematic effort to understand the values conflicts that underlie employee behaviors and how the organization 9s ethical environment and culture can be improved. IntegratedEthics provides structures and processes to develop practical solutions for improving ethics quality across all these content domains. Rules-Based and Values-Based Approaches to Ethics In addition to addressing ethics quality at all levels and across the full range of domains in which ethical concerns arise, the IntegratedEthics model takes into account both rules- and values-based approaches to ethics. Rules-based ethics programs are designed to prevent, detect, and punish violations of law.[25,26,30] Such programs tend to emphasize legal compliance by:[31] communicating minimal legal standards that employees must comply with monitoring employee behavior to assess compliance with these standards \x8 Part I: Introduction to IntegratedEthics instituting procedures to report employees who fail to comply disciplining offending employees In contrast, values-based approaches recognize that ethics means much more than mere compliance with the law. As one commentator put it: You can 9t write enough laws to tell us what to do at all times every day of the week . . . We 9ve got to develop the critical thinking and critical reasoning skills of our people because most of the ethical issues that we deal with are in the ethical gray areas.[32] For values-based ethics programs, it is not enough for employees to meet minimal legal standards; instead, they are expected to make well-considered judgments that translate organizational values into action 4especially in the cethical gray areas. d[25,26] To achieve this, values-based approaches to ethics seek to create an ethical environment and culture. They work to ensure that key values permeate all levels of an organization, are discussed openly and often, and become a part of everyday decision making. IntegratedEthics recognizes the importance of compliance with laws, regulations, and institutional policies, while promoting a values-oriented approach to ethics that looks beyond rules to inspire excellence. The IntegratedEthics Model An IntegratedEthics program improves ethics quality by targeting the three levels of quality 4decisions and actions, systems and processes, and environment and culture 4 through three core functions: ethics consultation, preventive ethics, and ethical leadership. Ethics Consultation When people make a decision or take an action, ethical concerns often arise. An ethics program must have an effective mechanism for responding to these concerns to help specific staff members, patients, and families. An ethics consultation service is one such mechanism. Today, every VA medical center has an ethics consultation service, but there 9s great variability across the VA health care system in terms of the knowledge, skills, and processes brought to bear in performing ethics consultation. Ethics consultation may be the only area in health care in which we allow staff who aren 9t required to meet clear professional standards, and whose qualifications and expertise can vary greatly, to be so deeply involved in critical, often life-and-death decisions. IntegratedEthics is designed to address that problem through CASES, a step-by-step approach to ensuring that ethics consultation is of high quality. The CASES approach was developed by the National Center for Ethics in Health Care to establish standards and systematize ethics consultation. ECWeb, a secure, web-based database tool, reinforces the CASES approach, helps ethics consultants manage consultation records, and supports quality improvement efforts. IntegratedEthics also provides assessment tools and educational materials to help ethics consultants enhance their proficiency. The CASES Approach C larify the consultation request A ssemble the relevant information S ynthesize the information E xplain the synthesis S upport the consultation process The CASES Approach C larify the consultation request A ssemble the relevant information S ynthesize the information E xplain the synthesis S upport the consultation process \x9 Part I: Introduction to IntegratedEthics Ethics consultation services handle both requests for consultation about specific ethical concerns and requests for general information, policy clarification, document review, discussion of hypothetical or historical cases, and ethical analysis of an organizational ethics question. By providing a forum for discussion and methods for careful analysis, effective ethics consultation: promotes health care practices consistent with high ethical standards helps to foster consensus and resolve conflicts in an atmosphere of respect honors participants 9 authority and values in the decision-making process educates participants to handle current and future ethical concerns Preventive Ethics Simply responding to individual ethics questions as they arise isn 9t enough. It 9s also essential to address the underlying systems and processes that influence behavior. Every ethics program needs a systematic approach for proactively identifying, prioritizing, and addressing concerns about ethics quality at the organizational level. That 9s the role of the IntegratedEthics preventive ethics function. To support preventive ethics, the National Center for Ethics in Health Care adapted proven quality improvement methodologies to create ISSUES 4a step-by-step method for addressing ethics quality gaps in health care. The IntegratedEthics Toolkit provides practical tools and educational materials to support facilities as they apply the ISSUES approach to improve ethics quality at a systems level. Preventive ethics aims to produce measurable improvements in an organization 9s ethics practices by implementing systems-level changes that reduce disparities between current practices and ideal practices. Specific quality improvement interventions in preventive ethics activities may include: redesigning work processes implementing checklists, reminders, and decision support evaluating organizational performance with respect to ethics practices developing policies and protocols that promote ethical practices designing education for patients and/or staff to address specific knowledge deficits offering incentives and rewards to motivate and reinforce ethical practices among staff Ethical Leadership Finally, it 9s important to deal directly with ethics quality at the level of an organization 9s environment and culture. Leaders play a critical role in creating, sustaining, and changing their organization 9s culture, through their own behavior and through the programs and activities they support and praise, as well as those they neglect and criticize. All leaders must undertake behaviors that foster an ethical environment 4one that 9s conducive to ethical practice and that effectively integrates ethics into the overall organizational culture. The ISSUES Approach I dentify an issue S tudy the issue S elect a strategy U ndertake a plan E valuate and adjust S ustain and spread The ISSUES Approach I dentify an issue S tudy the issue S elect a strategy U ndertake a plan E valuate and adjust S ustain and spread \xa Part I: Introduction to IntegratedEthics Leaders in the VA health care system have unique obligations that flow from their overlapping roles as public servants, providers of health care, and managers of both health care professionals and other staff. These obligations are sharpened by VA 9s commitment to providing health care to veterans as a public good, a mission born of the nation 9s gratitude to those who have served in its armed forces. As public servants, VA leaders are specifically responsible for maintaining public trust, placing duty above self-interest, and managing resources responsibly. As health care providers, VA leaders have a fiduciary obligation to meet the health care needs of individual patients in the context of an equitable, safe, effective, accessible, and compassionate health care delivery system.[33] As managers, VA leaders are responsible for creating a workplace culture based on integrity, accountability, fairness, and respect.[33] To fulfill these roles, VA leaders not only have an obligation to meet their f undamental ethical obligations, they also must ensure that employees throughout the organization are supported in adhering to high ethical standards. Because the behavior of individual employees is profoundly influenced by the culture in which those individuals work, the goal of ethical leadership 4and indeed, the responsibility of all leaders 4is to foster an ethical environment and culture. The ethical leadership function of IntegratedEthics calls on leaders to make clear through their words and actions that ethics is a priority, to communicate clear expectations for ethical practice, to practice ethical decision making, and to support their facility 9s ethics program. These four ccompass points d of ethical leadership are supported by tools and educational materials developed for IntegratedEthics. IntegratedEthics Program Management Two essential tasks for an IntegratedEthics program are to move ethics into the organizational mainstream and to coordinate ethics-related activities throughout the facility. This requires more than simply implementing the three core functions of IntegratedEthics; it also requires strong leadership support, involvement of multiple programs, and clear lines of accountability. These requirements are reflected in the structure recommended for IntegratedEthics programs within VA facilities. The IntegratedEthics Council provides the formal structure for the IntegratedEthics program at the facility level. The council: oversees the implementation of IntegratedEthics oversees the development of policy and education relating to IntegratedEthics oversees operation of IntegratedEthics functions ensures the coordination of ethics-related activities across the facility The Ethical Leadership Coordinator is a member of the facility 9s top leadership 4e.g., the director. The Ethical Leadership Coordinator ensures the overall success of the IntegratedEthics program by chairing the IntegratedEthics Council, championing the program, and directing the ethical leadership function. The IntegratedEthics Program Officer is responsible for the day-to-day management of the IntegratedEthics program, reporting directly to the Ethical Leadership Coordinator. The program officer works closely with the chair of the IntegratedEthics Council, functioning in the role of an executive director, administrative officer, or co-chair. The program officer should be a skilled manager and a well-respected member of the staff. \xb Part I: Introduction to IntegratedEthics The membership of the council also includes the Ethics Consultation Coordinator and the Preventive Ethics Coordinator, who lead the ethics consultation service and preventive ethics teams, respectively. Each role requires specific knowledge and skills. Finally, the council includes leaders and senior staff from programs and offices that encounter ethical concerns, for example: Chief of Staff Chief Fiscal Officer Associate Chief of Staff for Research Associate Chief of Staff for Education Patient Safety Officer Director, Quality Management Director, Human Resources Compliance & Business Integrity Officer Research Compliance Officer Information Security Office r Privacy Officer Nurse Manager In addition to overseeing the ethics consultation service and the preventive ethics team, the IntegratedEthics Council may also oversee standing subcommittees (e.g., policy, education, and JCAHO ethics readiness), as well as one or more ad hoc workgroups convened to address specific topics identified by the council. Standing Subcommittees (e.g., Policy, Education, Ethics Readiness) Member (e.g., Compliance Officer) Member (e.g., Privacy Officer) Member (e.g., ACOS/E) Member (e.g., Chief Fiscal Officer) Member (e.g., Chief of Staff) Ad Hoc Workgroups (e.g., advance directives, employee privacy) Member (e.g., ACOS/R) Member (e.g., Quality Manager) Member (e.g., Patient Safety Officer) Member Ethics Consultation Coordinator Member Preventive Ethics Coordinator Executive Director IntegratedEthics Program Officer Chair Ethical Leadership Coordinator (e.g., Facility Director) Preventive Ethics Team Ethics Consultation Service IntegratedEthics Council IntegratedEthics Program Structure \x30 Part I: Introduction to IntegratedEthics At the network level, IntegratedEthics is coordinated by the IntegratedEthics Point of Contact, who reports directly to the network director or the VISN Executive Leadership Council. In addition to serving as the primary point of contact with the National Center for Ethics in Health Care, this individual facilitates communication across facility IntegratedEthics programs and monitors their progress in implementing IntegratedEthics. Finally, a VISN-level IntegratedEthics Board helps to address ethical issues on a network level, especially those that cut across facility boundaries. IntegratedEthics Program Tools IntegratedEthics emphasizes distance learning and combines the use of print, video, and electronic media to provide a wide array of resources. These include reference materials and video courses relating to each of the three functions; operational manuals (toolkits) and administrative tools to help program staff organize and document their activities; assessment tools for evaluating program quality and effectiveness; communications materials about IntegratedEthics; and online learning modules to build staff knowledge of ethics topics. A New Paradigm for Ethics in Health Care IntegratedEthics builds on VA 9s reputation for quality and innovation in health care. Like VA 9s seminal work in performance management, its groundbreaking program in patient safety, and its highly acclaimed electronic medical record system, IntegratedEthics represents a paradigm shift. By defining ethics quality to encompass all three levels of the ciceberg, d the full range of ethics content domains, and both rules- and values-based approaches to ethics, IntegratedEthics provides a new way of thinking about ethics in health care. And its practical, user-friendly tools are designed to translate theory into practice 4to make ethics an integral part of what everyone does every day. IntegratedEthics refocuses an organization 9s approach to ethics in health care from a reactive, case-based endeavor in which various aspects of ethics (e.g., clinical, organizational, professional, research, business, government) are handled in a disjointed fashion, into a proactive, systems-oriented, comprehensive approach. It moves ethics out of institutional silos into collaborative relationships that cut across the organization. And it emphasizes that rules-oriented, compliance approaches and values-oriented, integrity approaches both play vital roles in the ethical life of organizations. By envisioning new ways of looking at ethical concerns in health care, new approaches for addressing them in all their complexity, and new channels for achieving integration across the system, IntegratedEthics empowers VA facilities and staff to cdo the right thing d because it 9s the right thing to do . From . . . To . . . Reactive Proactive Case based Systems oriented Narrow Comprehensive Silos Collaboration Punishment Motivation Rules Rules + Values From . . . To . . . Reactive Proactive Case based Systems oriented Narrow Comprehensive Silos Collaboration Punishment Motivation Rules Rules + Values \x3\x3 Part I: Introduction to IntegratedEthics Tool Function Ethics Consultation Preventive Ethics Ethical Leadership Reference Tools Primers Ethics Consultation: Responding to Ethics Questions in Health Care Preventive Ethics: Addressing Ethics Quality Gaps on a Systems Level Ethical Leadership: Fostering an Ethical Environment & Culture Easy Reference Tools CASES pocket card ISSUES pocket card Leadership bookmark Administrative Tools Ethics Case Consultation Summary & Template ECWeb Preventive Ethics ISSUES Log & Summary Preventive Ethics Meeting Minutes Preventive Ethics ISSUES Storyboards Preventive Ethics Summary of ISSUES Cycles IE master timeline Timelines for function coordinators Assessment Tools Ethics Consultant Profciency Assessment Tool Ethics Consultation Feedback Tool Ethical Leadership Self- Assessment Tool IntegratedEthics Facility Workbook (instrument, guide to understanding results) IntegratedEthics Staff Survey (introduction, survey instrument, FAQs) Education Tools Ethics consultation video course Training checklist & video exercises (1 34) Preventive ethics video course Training checklist & video exercise Ethical leadership video course Training checklist IntegratedEthics online learning modules: Ethics in Health Care, Shared Decision Making with Patients, Ethical Practices in End-of-Life Care, etc. Communications Materials Improving Ethics Quality: Looking Beneath the Surface IntegratedEthics: Closing the Ethics Quality Gap Business Case for Ethics IntegratedEthics poster IntegratedEthics brochure IntegratedEthics slides \x3 Part II: An Introduction to Ethics Consultation in Health Care For the purposes of this document, we define ethics consultation in health care as a service provided by an individual ethics consultant, ethics consultation team, or ethics committee to help patients, staff, and others resolve ethical concerns in a health care setting. The goals of ethics consultation The overall goal of ethics consultation is to improve health care quality by facilitating the resolution of ethical concerns . By providing a forum for discussion and methods for careful analysis, effective ethics consultation: promotes practices consistent with high ethical standards helps to foster consensus and resolve conflict in an atmosphere of respect honors participants 9 authority and values in the decision-making process educates participants to handle current and future ethical concerns A brief history of ethics consultation Ethics consultation in health care settings dates back nearly 35 years. In the 1970s the first consultation services were established. In the 1980s a professional society devoted to ethics consultation was formed, and the first books on ethics consultation were published.[34,35] In the mid-1990s a national consensus conference described goals of ethics consultation and methods for evaluating its quality and effectiveness.[36] In 1998 the ASBH published Core Competencies for Health Care Ethics Consultation , a report that describes the proficiencies required for health care ethics consultation.[37] Health care ethics consultation today Ethics consultation is now widely recognized as an essential part of health care delivery. The vast majority of U.S. hospitals have active ethics consultation services.[23] The Joint Commission for Accreditation of Healthcare Organizations requires that hospitals develop and implement a process to handle ethical concerns when they arise.[33] The Malcolm Baldrige National Quality Award Program recognizes cethical practices in all stakeholder transactions and interactions d as a key criterion for performance excellence.[27] Moreover, ethics consultation has been endorsed by numerous governmental and professional bodies and is legally mandated under specific circumstances in several states.[38] Part \x3I Introduction to Ethics Consultation in Health Care What Is Ethics Consultation in Health Care? \x3 Part II: An Introduction to Ethics Consultation in Health Care Effective ethics consultation has been shown to improve ethical decision making and practice, enhance patient and provider satisfaction, facilitate the resolution of disputes, and increase knowledge of health care ethics.[39] Moreover, ethics consultation has been shown to save health care institutions money by reducing the provision of nonbeneficial treatments, as well as lengths of stay.[9 312] The ethics consultation service It is therefore essential for every health care facility to have an effective local mechanism for responding to ethical concerns 4that is, an ethics consultation service . Ethics consultation services handle ethics case consultations as well as other types of consultations, including requests for general information, policy clarification, document review, discussion of hypothetical or historical cases, or ethical analysis of an organizational ethics question. What Models May Be Used to Perform Ethics Consultation? Health care ethics consultation may be performed by an individual ethics consultant, an ethics committee, or an ethics consultation team. As discussed below, each model has advantages and disadvantages. Although some ethics consultation services might rely exclusively on one of these three models, we generally recommend against this, since all three models have their place. Instead, for each consultation, the ethics consultation service should determine which model is most appropriate given the particular request . For example, some consultations can be best addressed by an individual consultant and some by the ethics committee or ethics consultation team model. Ethics consultation services should have consistent processes for determining how different types of consultations will be handled. Individual ethics consultant model In this model, one person 4either an independent csolo d consultant or a member of an ethics consultation team or committee 4is assigned to perform a given consultation individually. Advantages: most efficient model[23] fewer logistical hurdles (e.g., scheduling meetings) quicker response to urgent consultation requests Disadvantages: consultant must possess all required knowledge and skills fewer checks and balances to protect against consultants 9 personal biases It 9s incumbent on the individual ethics consultant to recognize his or her limitations and get help when needed. The successful ethics consultant will build a web of strong, collegial relationships in his or her facility and network and will call on others for assistance with \x3\x7 Part II: An Introduction to Ethics Consultation in Health Care particular ethical, legal, cultural, or religious concerns. Even the most highly trained and experienced ethics consultant benefits from discussing complex cases with outside experts. In addition, individual consultants should systematically seek feedback 4e.g., by reviewing completed consultations with colleagues. The individual ethics consultant model is generally appropriate only for the most straightforward consultations and for the most proficient ethics consultants. Ethics committee model In this model, a standing interdisciplinary committee 4that is, a relatively stable group of people (typically between 6 and 20) 4jointly performs a given consultation. Advantages: facilitates collective proficiency includes ready access to diverse perspectives and multidisciplinary expertise Disadvantages: requires a great deal of staff time not well suited to situations that require a rapid response diffusion of responsibility across committee members can contribute to complacency and cgroupthink d patients and family members may feel intimidated by a large group of professionals The committee model may be especially useful for ensuring broad organizational input into difficult consultations, including those that might establish precedent or end up in the media or the courts. This model may also be useful to facilities that are relatively new to ethics consultation, handle a low volume of consultations, and/or lack specialized ethics expertise. Ethics consultation team model In this model, responsibility for a given ethics consultation is shared by a small group of qualified consultants chosen on the basis of their complementary perspectives and expertise relevant to the circumstances. Advantages: several perspectives and diverse expertise flexibility for a rapid response composition of team can vary to meet the situation less intimidating than the committee model for patients and families a natural forum for support and reflection Disadvantages: less efficient than the individual consultant model fewer checks and balances than the committee model This model allows for tasks to be divided among members of the team. For example, it is not necessary for every team member to go to the patient 9s bedside or attend a family meeting. A single member may perform both roles and then report back to the others on \x3\x8 Part II: An Introduction to Ethics Consultation in Health Care the team. Deciding which member of the team has the best skills and knowledge to take the lead for a particular consultation calls for insight and good judgment. The team model accommodates a wide range of situations and levels of consultant expertise and is in some ways a compromise between the individual and committee models . It 9s used more commonly than other models 4two-thirds of hospitals in the United States, both within and outside VA, indicate that they use the team model more commonly than they do either the individual or the committee model.[23] \x3\x8 What Proficiencies Are Required to Perform Ethics Consultation? The 1998 ASBH report Core Competencies for Health Care Ethics Consultation [37] discusses the knowledge, skills, and character traits required for ethics consultation and notes that when an individual consultant performs ethics consultation, the consultant must have advanced knowledge and skills across multiple areas. In contrast, when the team or committee model is used, requisite knowledge and skills can be distributed across the various members of the group. Of course, the greater the collective expertise in an ethics consultation service, the more useful and effective that service will be. Although basic knowledge and skills may be developed through practical experience, development of advanced knowledge and skills generally requires a more rigorous and systematic approach to learning (e.g., formal coursework, in-depth reading and discussion, supervised practice with feedback). The knowledge, skills, and character traits described below are adapted from the ASBH report. Knowledge Successful ethics consultation requires knowledge of: moral reasoning and ethics theory, including familiarity with a variety of approaches to ethical analysis, such as principle-based and casuist ethical issues and concepts in the areas of shared decision making, end-of-life care, privacy and confidentiality, professionalism, resource allocation, research, business and management ethics, ethics of government service, and ethics of the everyday workplace health care practices, especially clinical literacy 4i.e., the ability to understand medical terms, and descriptions of disease processes, treatments, and prognoses; familiarity with medical decision making, current or emerging technologies, and the different roles, relationships, and expertise of health care providers cultural and religious issues, including how culture, religious tradition, ethnicity, beliefs, and perspectives shape both providers 9 and patients 9 responses to illness death, and medical treatment \x3\x9 Part II: An Introduction to Ethics Consultation in Health Care health care environment, including VHA and local facility mission statements, organizational structures, range of service and points of care, and policies (e.g., informed consent, advance directives, privacy and confidentiality, organ and tissue donation, medical records) health law, significant legal cases and concepts, and relevant codes of ethics and professional conduct Skills Ethics consultation also requires specific skills. Those who perform ethics consultation must be able to: identify the nature of the uncertainty at the heart of the case analyze the ethical concerns identify and evaluate the ethically justifiable options facilitate formal and informal meetings, including those involving highly charged issues or participants who may be emotionally distressed build consensus when there are competing moral views and/or multiple ethically justifiable options collect and verify clinical and other relevant information demonstrate critical thinking listen well communicate effectively and respectfully recognize and address barriers to communication foster a respectful, supportive environment for expression of moral views educate participants about ethical issues document consultations in the health and consultation service records use institutional resources effectively evaluate consultations Character traits Ethics consultants should also display certain character traits. For example, when appropriate, consultants should exhibit: Individuals who are unable to demonstrate these traits when the situation demands it are generally not well suited to perform ethics consultation. A tool for evaluating the proficiency of ethics consultants is available on the Center 9s website, vaww.ethics.va.gov/IntegratedEthics or www.ethics.va.gov/IntegratedEthics . humility forthrightness tolerance self-knowledge patience prudence compassion integrity honesty courage humility forthrightness tolerance self-knowledge patience prudence compassion integrity honesty courage \x3\xa Part II: An Introduction to Ethics Consultation in Health Care What Are the Critical Success Factors for Ethics Consultation? In complex organizations certain factors are generally predictive of the likelihood that a specialized service will achieve its goals. To provide an effective mechanism for addressing ethical concerns in health care, a consultation service must have integration, leadership support, expertise, staff time, and resources. Access, accountability, organizational learning, and evaluation are additional factors that should be ensured. Because all these factors are critical for the success of ethics consultation services, each should be addressed in policy. Integration The successful ethics consultation service doesn 9t function as a silo; it develops and maintains positive relationships with the various individuals and programs that shape the organization 9s ethical environment and practices. In this way, it serves the entire institution, not just a particular category of staff (such as physicians), a particular setting (such as intensive care), or a particular clinical service (such as surgery). A fully integrated ethics consultation service responds directly to a wide range of ethical concerns faced by the organization, including concerns involving shared decision making with patients, ethical practices in end-of-life care, patient privacy and confidentiality, professionalism in patient care, and ethical practices in resource allocation. And by establishing effective working relationships across the organization, a fully integrated ethics consultation service carries out its activities in coordination with other offices and programs that address ethical concerns in other domains, such as business and management, government service, research, or workplace interactions, and is available as an ethics resource for the organization as a whole, not just for clinical services. The ethics consultation service should look for opportunities to share activities and skills, or to identify and work to achieve mutual goals. For example, the ethics consultation service might enlist the facility 9s quality management program to help evaluate the service 9s performance. In addition, the ethics consultation service should develop ongoing working relationships with other facility programs and departments that commonly encounter ethics-related issues (e.g., chaplain service, patient advocate program, legal counsel, research, compliance and business integrity, human resources). The establishment of these relationships will help promote collaboration and ensure that staff members across different services and programs understand one another 9s skills and roles, thereby contributing to the overall efficiency of the organization. The structure of an IntegratedEthics program is designed to promote and support such relationships through a local IntegratedEthics Council responsible for bringing together leaders from key offices and programs, including coordinators of the three core IntegratedEthics functions (ethics consultation, preventive ethics, and ethical leadership), and coordinating ethics-related activities across the organization. Leadership support Explicit leadership support is essential if the goals of ethics consultation are to be realized. Ultimately, leaders are responsible for the success of all programs, and health care ethics consultation is no exception. It 9s leaders who establish organizational priorities and allocate resources to support those priorities. Unless leaders support 4and are perceived to support 4the ethics consultation function in a facility, the consultation function cannot succeed. \x3\xb Part II: An Introduction to Ethics Consultation in Health Care Leaders at all levels and throughout the organization can and should support an ethics consultation service in several ways: understand the scope and role of the ethics consultation service seek advice from the ethics consultation service when appropriate encourage others to utilize the ethics consultation service Leaders who supervise employees who are members of the ethics consultation service should also: include responsibilities of ethics consultation in staff performance plans recognize staff for their ethics consultation activities Finally, top organization leadership 4i.e., leaders at the executive leadership and mid- manager level 4should: keep up to date on the activities of the ethics consultation service regularly update staff on those activities ensure that other critical success factors are in place, as described below Expertise Leaders of health care facilities as well as those who are responsible for ethics consultation should ensure that consultation services have the requisite expertise. Regardless of the consultation model used, all the proficiencies outlined in the previous section of this document must be represented in the ethics consultation service. Individual members of the service may have different proficiencies, and some proficiencies may be represented by only one person. Collectively, however, the full set of core competencies noted above must be represented on the service and available when needed for a particular consultation. Most facilities should recruit or train their own in-house ethics consultants. When in-house expertise is not sufficient, facilities need to arrange access to outside experts. For example, some VA facilities engage the services of an outside ethics consultant on a contractual or fee basis 4this may be most appropriate for small facilities that handle only a few consultations a year. Other facilities may choose to establish agreements with a university affiliate 9s health care ethics program. A tool for evaluating the proficiency of ethics consultants is available on the Center 9s website, vaww.ethics.va.gov/IntegratedEthics or www.ethics.va.gov/IntegratedEthics . Staff time Facility leaders should also ensure that adequate staff time is available for ethics consultation activities. Ethics consultation can be time consuming and individuals responsible for this service need dedicated time to do their work. In a given facility, the time required for ethics consultation will vary depending on the types of consultations handled.[23] For example, even a straightforward ethics consultation will typically take several person-hours, while complex cases 4especially those that are novel or precedent setting 4may require many hours from multiple individuals over an extended period. Depending on the circumstances, a consultation may take a week or more and add up to 20 person-hours or more of effort. \x40 Part II: An Introduction to Ethics Consultation in Health Care Ethics consultation services handle a variety of requests. Although the major part of consultants 9 time is likely to be devoted to helping address ethical concerns as they arise in the care of individual patients, consultants are also asked for assistance with many other matters. For example, the service may receive requests for general information or education, clarification of policy, review of documents, ethical analysis of hypothetical or historical cases, or organizational ethics questions. When all the person-hours devoted to ethics consultation are taken into account, the most active of ethics consultation services may require a time commitment equivalent to a dedicated full-time staff member (FTE). And this doesn 9t take into account other ethics-related responsibilities individual consultants may have, such as helping to develop policy or educating staff about ethics. Consultation should not be viewed as an optional or voluntary activity, but as an assigned part of employees 9 jobs that requires dedicated time. Individuals who participate in ethics consultation should have a clear understanding with their supervisors about how much time this activity involves. Resources Leaders of health care facilities should also ensure that individuals who perform ethics consultation have ready access to needed resources, such as workspace, clerical or data entry support, library materials, and ongoing training, to name a few. Many useful ethics resources are available online, so access to the Internet is essential as well. The National Center for Ethics in Health Care has developed a var

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