As a consultant who helps healthcare organizations with their ethics programs, Ellen Fox, MD, often finds people want to evaluate quality but don’t know where to begin.

“When they look to the published literature for help, the evaluation methods they read about seem overly complicated, or impractical, or not a good fit for their organization,” says Fox, director of the Washington, DC-based Center for Ethics in Health Care of Altarum Institute. Fox is professor of bioethics at Clarkson University in Potsdam, NY, and founder of Fox Ethics Consulting in Arlington, VA. She suggests starting with the following three questions:

1. Have we established clear and specific quality standards?

Few organizations have clear and specific policies to guide the practices of their ethics programs. Establishing these is a good starting point, according to Fox.

Many hospital policies aren’t specific enough for evaluation purposes. For example, a policy might say that members of the consult service will interview the patient and other stakeholders “as appropriate.”

“To be useful for quality evaluation, this standard would need to clearly specify who should be interviewed under what circumstances,” says Fox.

2. Are the quality standards we have established consistent with widely accepted industry standards?

“Some hospitals have established clear standards that are problematic,” says Fox. For example, an ethics consult service might have a policy that says only attending physicians can request ethics consultations — whereas the accepted industry standard is that anyone with standing in a case should be able to request an ethics consultation.

“While there is no single authoritative source for quality standards in ethics consultation, I recommend two resources that were extensively vetted by stakeholders from multiple healthcare organizations,” says Fox. These are the American Society for Bioethics and Humanities (ASBH)’s Core Competencies for Healthcare Ethics Consultation ( and the VHA’s primer on Ethics Consultation (

3. Are we consistently following our own quality standards?

“Some hospitals have clear standards, but they don’t follow them — or at least not consistently,” says Fox. Fox recently consulted for a healthcare system with detailed policies on ethics consultation procedures. “But when I interviewed stakeholders at one of the system’s hospitals, they told me that the policies were completely ignored,” says Fox.

Once clear standards are established, it’s a relatively simple matter to assess program performance relative to those standards. “I often recommend to hospitals that they do this sort of evaluation before they undertake evaluations of other things such as access, satisfaction, or outcomes,” says Fox.

Fox was lead author of a 2007 national study on ethics consultation in U.S. hospitals, which found that only 28% formally evaluated the consultations they performed.1 In almost half of hospitals that had a formal evaluation process, the process involved nothing more than an internal review and discussion of case records by members of the consult service.

“The study is more than 15 years old, so the situation may have changed,” Fox acknowledges. “But in my experience, rigorous evaluation of ethics consultation services is still rare.”

Updated Data Coming

Updated data on evaluation practices are forthcoming, with a research study underway at the Altarum Institute’s Center for Ethics in Health Care. “We will ask a random sample of 600 U.S. hospitals about their ethics consultation practices and their views on potential improvement strategies,” says Fox. The study, funded by the Greenwall Foundation, will answer the following questions:

  • How have ethics consultation services changed since the prior national study?
  • How do ethics consultation practices compare with the standards articulated in the ASBH Core Competencies report?
  • What do ethics practitioners think about ethics consultation? For example, do they believe the resources devoted to ethics consultation are sufficient?
  • What strategies to improve ethics consultation do they think would be most effective?
  • How much do hospital administrators know about ethics consultation services? Do their perspectives differ from those of ethics practitioners?

Part two of the study will involve a systematic review of 300 ethics consultation records from 100 hospitals.

“We are developing and testing a new tool to score the quality of these records, building on the Ethics Consultation Quality Assessment Tool I developed with my former colleagues at VA’s National Center for Ethics in Health Care,” says Fox.


  1. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth 2007; 7(2):13-25.