AMA unveils health care ethics program, toolkit

Eight hospitals will be field-testing program

The Ethical Force Program, a collaborative effort of the American Medical Association (AMA) to develop health care systemwide performance measures for ethics, will be field-testing a tool kit on patient-centered communication with diverse populations from March to December 2006 with eight volunteer hospitals and eight physician groups. The program aims to overcome communication barriers that are prevalent in vulnerable minority populations, with the expectation of reducing racial and ethnic disparities in health care.

Eight hospitals and eight large physician practices are being selected from across the country to field-test the patient-centered communication tool kit. In addition to being able to use the toolkit at no cost, they will:

  • receive a comprehensive report on their assessment results from Ethical Force Program staff;
  • collaborate with a research team and hospitals and physician practices across the country, share insights, and learn from what others are doing;
  • evaluate their organization’s commitment to communicating effectively with all patient groups.

What the program does

The Ethical Force program is a means for developing mutual and multilateral accountability in ethics among all participants in the health care delivery system. It is charged with creating, testing, and disseminating performance measures for domains of ethics in health care. The program is directed by a 23-member oversight body, which includes representatives from numerous relevant groups, including patients, practitioners, health plans, purchasers, government, and accrediting organizations. The oversight body members are elected to serve up to two three-year terms, says Ron Davis, MD, AMA Trustee.

Increasingly, physicians and managed care organizations are being held accountable for quality of care based on the processes and outcomes of medical care and patient satisfaction. "But high-quality health care delivery involves more than good technical quality and acceptable customer service," says Davis. "It also means upholding high ethical standards. Health care is ultimately a moral enterprise, built on protecting the potential extraordinary vulnerability of patients. It is grounded in a covenant of trust, which relies on every part of the health care system living up to shared ethical norms."

Measuring the full-spectrum of health care quality, therefore, requires developing explicit shared sets of expectations for ethical behavior across the full range of parties involved in health care delivery and then learning how to measure performance in meeting these expectations.

Like so-called "condition-specific" performance measures, Ethical Force performance measures for ethics quality will include questions that can be placed into practitioner and patient surveys, as well as easy-to-use site review criteria and policy review criteria. The measures will be distributed — with grading instruction and examples of good performance — in Ethics Performance Measurement "Toolkits," which can be easily and inexpensively used to measure organizational performance in specific domains of ethics.

"The first stage of the Ethical Force Program’s process is to develop a consensus report on each topic it addresses," Davis says. "These consensus reports include a set of performance expectations that all organizations in health care should be able to meet."

The second stage of the Ethical Force Program’s process is to translate the expectations into performance measurement tools. This means translating the expectations into survey questions that organizations can use for self-assessment. "The toolkits developed by the Ethical Force Program include patient surveys, staff surveys, policy checklists, and workbooks to determine how well the organization believes it is implementing its policies," says Davis.

"The results of the assessment compare how the organization views its performance with how its patients and staff view the organization’s performance."

The first two "domains" that have been selected for ethics performance measure development are (1) privacy and confidentiality protections in health care; and (2) processes for designing health benefits and adjudicating coverage decisions.

"The oversight body recognizes that the integrity and fairness of processes for making health coverage decisions are important factors in fostering trust in health care organizations," notes Davis, "But, coverage decisions can be ethically complex. Within the context of designing and administering a benefits package, each stakeholder has unique, and sometimes conflicting, responsibilities that must be weighed against one another. The Ethical Force framework provides a means to help balance these competing demands and ethical obligations."

The Ethical Force Program expects that organizational processes for designing and administering health benefits should be: transparent, participatory, equitable and consistent, sensitive to value, and compassionate. Within each of these areas, the Ethical Force Program outlines expectations for organizational performance (

No gold standard

While there are no gold standards for many aspects of ethics in health care, this does not make ethical performance unmeasurable, Davis says. Many aspects of clinical care also do not have gold standards for performance, he notes, yet performance measures still are used to assess performance in these areas. For areas with no clear gold standard for performance, measures focus on assessing (1) whether baseline expectations have been met, (2) whether progress is being made towards aspirational goals, and (3) whether acceptable processes are being used to ensure that difficult issues are appropriately addressed.

Once field-testing is complete, Ethical Force Performance Measures Toolkits will be available at cost on the Ethical Force web site and through the Ethical Force National Program Office at the Institute for Ethics at the AMA. At that point, says Davis, quality managers should play an important role in seeing that their facilities participate. "The quality manager is well placed to advocate for or coordinate this type of self-assessment effort," he says. "While some quality managers may not have the knowledge to complete the organizational pieces of the assessment on their own, they can bring together a team to inform this process. The quality manager should also be familiar with the organization’s strategies for surveying patients and staff."

Finally, he notes, the quality manager will have the skills needed to compare the organization’s performance on ethical topics with its performance in other areas.

For more information about the Ethical Force program, contact the program staff at the Institute for Ethics at (312) 464-4698 or (312) 464-4075.