Is an ethics consultant highly qualified and able to demonstrate his or her knowledge with an impressive portfolio of cases? That’s important information to know, but it’s not enough for Kenneth Berkowitz, MD, FCCP, chief of ethics consultation at Veterans Health Administration (VHA)’s National Center for Ethics in Health Care.
“It doesn’t tell you if the quality of the overall ethics consultation service is enough to meet the needs of the patients, the staff, and the institution,” explains Berkowitz.
The VHA goes beyond assessing an individual consultant’s proficiency. “We need to have proficient consultants performing high-quality consultations in a manner that meets the needs of the patients, family, staff, and institutions they serve,” says Berkowitz.
Individual consultants may have a great deal of expertise in ethical issues that arise in the ICU, for instance — but a surgeon routinely discourages nurses from calling ethics consults. “To me, that’s not a high-quality ethics consultation service,” says Berkowitz.
Access, throughput, timeliness, and participation in organizational learning are all critical success factors. “All of these things are beyond just doing a good consult, but they are part of having a high-quality consultation service,” says Berkowitz.
Berkowitz says that currently, many ethics programs in this country “lack consistent standards and are undersupported, and it’s very problematic.”
Mary Beth Foglia, RN, PhD, a healthcare ethicist at the center’s Seattle office, says, “Ultimately, improving consultation quality is about ensuring ethically appropriate outcomes for patients, other stakeholders, and the healthcare system.”
The VHA’s 15-year effort has focused on improving the quality of its own ethics programs, but also provides tools to improve ethics consultation in general.
“We’ve tried to tackle ethics consultation quality over the years in terms of structure, processes, and outcomes,” says Berkowitz. The following are some ways the VHA has done this:
• During site visits to individual facilities, the team looks at how the ethics program is functioning.
“We talk to the leaders and also people in the trenches — doctors, nurses, social workers, patients, and families — to find out if the program is functioning as well as it looks on paper,” says Berkowitz.
Berkowitz says the following are important questions to ask about an ethics program:
- Does the overall ethics program have leadership support?
- Do people feel comfortable bringing up ethical concerns?
- Does the ethics consultation service contribute to organizational learning?
- Is there good access to the ethics consultation service?
- Does the service focus on quality improvement (QI)?
- Does the service assure competency in the full range of ethical questions that might come up, both clinical and organizational?
Berkowitz says that evaluation of healthcare ethics activities should be viewed in the same light as other clinical areas.
“You can have a board-certified transplant surgeon, but if the transplant program isn’t functioning well, it doesn’t matter how the good the surgeon is,” he says. A successful transplant program encompasses more than just individual surgeons’ outcomes — it assesses access, fairness, infection rates, patient satisfaction, and multiple other factors. The same is true of ethics, he says.
“I hope that, in addition to assessing individual consultants, there will be a growing movement to evaluate the ethics consultation service at the organizational level,” says Berkowitz. “That is my vision for where we need to go as a field.”
• The VA developed a standardized process approach to performing ethics consultations.
“Part of the reason why we are so process-focused and structured is that we have to promote consistency within our system,” explains Berkowitz.
The CASES Approach (Clarify/Assemble/Synthesize/Explain/Support) was developed over several years, with experts both inside and outside the VHA.
“It’s a consistent and systematic process,” says Berkowitz. “It’s a logical way to think through each ethics question.” The center is responsible for ethics consultation services at the VHA’s 150 medical centers. “There may be 150 ways to do it, but we need to come up with one way, and say at the VHA, ‘This is how we’re going to do it,’” says Berkowitz. “This is necessary in order to assess how ethics is doing, and for continuous quality improvement.”
Ethicists take the following steps:
- clarify the consultation request and the ethics question,
- assemble relevant information necessary to fully understand the circumstances,
- synthesize the information and perform an analysis from an ethics perspective,
- explain the synthesis to those who are involved, and
- support the consultation process by providing references, answering questions, continuing as a resource if further concerns or specific cases come up, and performing evaluation.
The CASES approach applies equally well to organizational questions as it does to individual cases.
On the individual case level, a consult might be requested because there was uncertainty or conflict about values surrounding a patient’s request to have his or her automatic implanted cardioverter defibrillator (AICD) deactivated. Providers are uncomfortable because they wonder if it’s akin to participating in physician-assisted suicide, yet they recognize the patient’s right to make choices about his or her own healthcare.
At the organizational level, the chief of cardiology might call to request a consult to review the ethical considerations of AICDs for patients at the end of life in general. “We can help them think through the general concepts involved. The CASES approach provides a great framework for that,” says Berkowitz.
• The VA developed ECWeb, a quality assurance software tool.
The tool has been in use systemwide since 2008, and contains records of more than 18,000 ethics consultations.
“Not only is ECWeb a repository of information and useful for quality improvement and education, but the way the data is entered reinforces the use of the CASES approach and promotes strong processes for ethics consultation,” says Berkowitz.
VHA efforts are currently underway to develop IEWeb, the second generation of the software. The tool will have improved and streamlined ethics consultation functionality, and will also help with preventive ethics. “It will be much broader in scope and functionality. We hope it will also have applicability for systems outside of VHA,” says Berkowitz.
Through the preventive ethics function, the updated software will help teams address systems issues that ethics programs also work on. For instance, there may be a pattern of consults called by ICU clinicians because there was an advance directive in place that the team wasn’t aware of until a week or so into the patient’s care. “We would say there was a systems issue there,” says Berkowitz. “Why didn’t the team know about the directives on day one?” IEWeb would help ethicists to study the problem and prevent it from occurring again.
“It will help people close ethics quality gaps when practices don’t match the ethics standards,” says Berkowitz.
• Participants are routinely asked for feedback about ethics consults.
Outcomes are challenging to evaluate. “We can benefit from learning about the experience of those who participated in ethics consultations,” says Berkowitz.
Participants in an ethics consult are surveyed about their overall satisfaction with the consultation, and whether it was helpful.
“They also are asked questions that reflect their perception of the ASBH knowledge and skills competencies for ethics consultants,” says Berkowitz. Surveys address ease of access, timeliness, whether the participant felt treated with respect, and their perception of the consultant’s expertise and competence.
“Looking back at five years of data, over one-third of all VHA consults received feedback from participants, which I think is amazing,” says Berkowitz.
In over three-quarters of the evaluations, participants reported that recommendations were both made and followed. “To me, that’s a strong assessment that the consultations had impact,” Berkowitz says.
• The ECQAT tool was developed to help the VA’s 150 supported consult services to identify improvement opportunities based on the key elements.
“Somehow we have to be able to assess whether the content of the consultation reflects strong practices and is consistent with ethical norms,” says Berkowitz. The ECQAT tool was designed to support assessment of the quality of ethics consultations, based on the written record.1
“We needed to find some way to assess the quality of the content. That was the seminal concept of the ECQAT project,” says Berkowitz. “There’s no way around having some sort of standard rubric, with experts assessing the record.”
Foglia says, “As with any clinical service, whether clinical ethics consultation or cardiology, we have an obligation to develop approaches to assessing and improving the quality of the service provided.”
As a starting point, ethicists identified and described four key elements that must be present in every consultation. “These elements are intended to serve as standards for all ethics consultation case records, regardless of the model used,” says Foglia.
The key elements are:
- the ethics question(s), which focuses the consultation response,
- the consultation-specific information, which informs the ethical analysis,
- the ethical analysis, which provides justification for the conclusions and/or recommendations, and
- the conclusions and/or recommendations, which promote ethical practices in the area of identified uncertainty or conflict.
“The tool uses a holistic assessment method, reflecting the importance of the interdependence and coherence among the key elements in a consultation,” says Berkowitz. The following are some ways the ECQAT can be used:
- Key elements can be used to inform case discussions, and for training or coaching purposes.
- Ethicists can use it in real time to promote quality consultation.
- Evaluators can periodically select a random sample of consultation records and identify improvement opportunities.
“People may say it’s not fair to judge the quality of the consult from the record, but that’s the way much of healthcare quality is judged now,” Berkowitz says.
- Pearlman RA, Foglia MB, Fox E, et al. Ethics consultation quality assessment tool: A novel method for assessing the quality of ethics case consultations based on written records. Amer J Bioethics 2016; 16(3):3-14.
- Kenneth Berkowitz, MD, FCCP, Chief of Ethics Consultation National Center for Ethics in Health Care, Veterans Health Administration, Seattle. Phone: (212) 951-3385. Email: Kenneth.Berkowitz@va.gov.
- Mary Beth Foglia, RN, PhD, National Center for Ethics in Health Care, Veterans Health Administration, Seattle. Phone: (206) 940-9692. Email: Marybeth.Foglia@va.gov.
- A wide range of materials and tools related to VHA’s approach to ethics consultation are available to the general public, free of charge, at: http://bit.ly/2jzYKC1.