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Kaiser Permanente changes landscape for hospital ethics
While most people know Kaiser Permanente is a managed care organization, what many might not know is that it encompasses eight states, and the southern California region of Kaiser instituted a distinctive bioethics program that is unlike any other.
"Our program is distinctive because we have a dedicated clinical staff ethicist at each of our medical centers, with a very well-defined structure that provides support to the individual bioethicist. This enables the bioethicists to leverage their expertise in facilitating bioethics consultations and serving as co-chairs of their medical center bioethics committee," says Paula Goodman-Crews, MSW, LCSW, co-director of the Kaiser Permanente Southern California Bioethics Program.
At the medical center committee level, positioning within the hospital structure enables the medical center's institutional bioethics committee to develop working relationships with many stakeholder groups such as quality management, risk, nursing and physician leadership, and compliance. "Not only do we have leadership from each of these areas participating in the bioethics committee meetings, but our bioethicists are 'at the table' and contribute to several multidisciplinary committees involving several departments and disciplines," says Goodman-Crews.
Southern California Regional Bioethics Committee provides policy, education, and consultation based on collaboration at multiple hospital centers. It is not government-financed and not academic-based. This bioethics program has paid full-time staff. Decisions are evaluated by multiple metrics and are overseen by multiple individuals and all preconceived outcomes are documented.
Malcolm Shaner, MD, co-director of the Kaiser Permanente Southern California Bioethics Program, Los Angeles, says, "The program began in 2008 with the hiring of our clinical ethicists and was given official 'birth' in June 2010 with our first report to the Kaiser Permanente Southern California Quality Committee."
The special program for bioethics was prompted from a leadership perspective in the Southern California region, says Patti Harvey, RN, MPH, CPHQ, vice president of quality and risk management, Kaiser Foundation Hospitals and Health Plan Southern California, Pasadena. "There was keen interest in developing a clinical/medical bioethics program that would support our care providers and our patients in their decision-making processes," Harvey says. The value of clinical ethicist support is important in creating an integrated patient care experience, she adds. "The ability to have a clinical ethicist at the bedside as a part of the care delivery team provides an environment conducive to thoughtful discussions that can lead to more agreement and understanding about the patient's care," Harvey says.
Shaner says, "Since about 1986, we built a 'moral community' holding quarterly meetings of the chairs of the Committees on Bioethics across the Southern California service areas, which now number 13. We exchanged visions of a program in bioethics and considered carefully models for such a program." In 2008, leaders of the Kaiser Foundation Hospital and Health Plan and the Southern California Permanente Medical Group provided them the resources that would allow the carefully thought-out plans to move forward, according to Shaner.
Goodman-Crews adds, "We leveraged an established regional ethics committee and, with our internal experts, we began to design, build, and implement a clinical/medical ethics program within each of our medical centers. From the early years, our best practices propelled us to expand the program. For example, the medical bioethics director position that was developed in San Diego became a model for replication across the region." Within the program, they grew the number of clinical ethicists incrementally over three years according to Goodman-Crews.
One special aspect of this regional bioethics program is the variety of disciplines represented in the clinical ethicist group itself. Vincent Guss, DMin, BCC, medical ethics director, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, says, "Although each of us has had extensive clinical training and experience in bioethics as a discipline, most of us began in another healthcare discipline including medicine, nursing, social work, philosophy, law, laboratory science, theology, and pastoral care."
A needed program in a changing setting
The evolving medical landscape provides a field where the diverse values of a pluralistic society play out, Shaner says.
"These familiar themes are expressed in a myriad of circumstances but can be sketched along the lines of different answers to deep questions and incomplete agreement over the best means to promote the good of an individual patient and optimal ways to improve the health of our society," he adds. "Our Kaiser Permanente Medical Care Program in Southern California feels that in keeping with our integrated approach to medicine, we require an approach to these often-emotional clinical situations based on an examination of deep, foundational questions. We see a need to adopt a considered approach that results from ongoing, responsible reflection that respects the needs of our patients, our medical professionals, and our society."
The program works a great deal differently than other medical centers. Shaner says, "Our program is piloted in the Southern California Region of Kaiser Permanente. Kaiser Permanente is unique because it is both a health plan and a provider." Specifically, the framework includes the capitated, not-for-profit Kaiser Foundation Hospitals and Health Plan and the medical partnership, Southern California Permanente Medical Group, serving some 3.5 million members. "This structure distinguishes us from most medical groups in private practice. In addition, while we have educational programs and we are affiliated with teaching programs, we are not an academic institution. We are not funded by the United States government, as are the Veterans Administration Medical Centers.
"We have a medical program integrated tightly among the health plan, hospitals, and medical group," says Shaner. Decreased fragmentation might be one key to achieving the goals of the pilot program in bioethics within the Southern California Region, he adds.
Looking ahead to the future
The ethicists involved with Southern California Regional Bioethics Committee are prepared to face the considerable challenges in the future including the continuing and changing metrics, and work toward continuous improvement for clinical ethicists, medical centers, and the program as a whole. The committee develops standards of ethical practice across the region by developing policy, identifying ethics quality improvement opportunities, self-education, and professional education. The results are shared across the region.
Harvey says, "From a leadership perspective, the value of our clinical ethicist program is just beginning to take off. With our increased membership and the growing importance of bringing our member's voices to the forefront, our bioethicists help us shape our decisions, programs, and strategies to ensure that we are responsive and supportive of our caregivers and our members."
Guss adds, "There is a strong sense of solidarity, mutual accountability, respect, and collegiality among the ethicists who meet each month to address regional bioethics issues we all face. There is mutual support and guidance for each other when addressing complex cases and situations in each of the ethicist's own medical center."
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Bioethicists from around the nation will learn more about Kaiser Permanente Southern California Regional Bioethics Committee, how it developed, its current mission, and its vision for the future on Oct. 15, 2011, when the ethicists from this regional program will provide a presentation at the annual conference of the American Society of Bioethics and Humanities (ASBH) at the Hyatt Regency Minneapolis (MN). For more information, see http://www.asbh.org.