EXECUTIVE SUMMARY

Assessing quality of ethics consultations is difficult due to lack of resources and easily measurable outcomes. Some approaches include the following:

  • include specific process measures in policies;
  • look for trends in timeliness of responses to requests;
  • enlist the help of colleagues with data analysis skills.

Quality of clinical care routinely is assessed using myriad established approaches, with patient safety issues addressed with such proven methods as root cause analyses. On the other hand, quality of ethics consultations often is not addressed at all.

“My perception is that I don’t think most places do assess the quality of their consults,” says Timothy Kirk, PhD, assistant professor of philosophy at the City University of New York-York College in Jamaica.

Lack of required expertise and unclear criteria make such assessment challenging, but Kirk says it’s important to remember that a bad consult is worse than no consult at all. Poorly performed, ethics consults can lead to the wrong people being involved in decision-making, violation of patients’ rights, and exposure to legal risk.

“Consults are not neutral. Like any intervention, they can bring both benefit and harm,” says Kirk. “If you are not tuned into that, you may not see the value of quality assessment.”

“What are you trying to assess?” and “What are the best ways to assess it?” are surprisingly difficult questions to answer when it comes to measuring the quality of ethics consults.

“If you are going to assess anything, you have to identify the quality measures up front,” says Kirk. “Only if you have clear goals can you afterward assess if the goals were met.”

A well-crafted ethics consult policy can help with this. Are ethicists required to review the chart and consult with stakeholders, and hold family meetings? If so, says Kirk, “one way to assess quality is to assess those process measures.”

Timeliness of consultants’ responses also is easy to quantify, with a feedback mechanism from users on how quickly requests for consults were met. For instance, the policy might state that a consultant should respond to a request within six hours. If only three consultants responded in the target time frame for 24 requests, it could reveal a problem in how requests are coming in. “It might be that they are coming in through an email portal, and it’s difficult to check because none of the consultants have access to it from their smartphones,” says Kirk. In this case, it might be better for requests to come in through phone calls.

Outcomes measures are harder to assess. “Policies don’t always identify what the outcomes of a successful consultation would be,” says Kirk. Some policies aren’t clear enough on this point. Another confounding factor is that the outcomes measures for a successful consult differ, depending on the issue at hand.

If family members disagree with one another on a treatment plan for their mother, it would seem logical to use resolution of the conflict as an outcome. “But even that is not necessarily a realistic outcome to hope for,” says Kirk.

Even if the ethicists employ top-notch mediation skills during a lengthy family meeting, the outcome could be that the family still disagrees. “I’m not sure that means it was a bad consult. It means it was a hard family,” says Kirk.

Kirk says that the question of whether the ethics consult affected the care that was delivered is particularly difficult to answer. Categorizing consults, then identifying an outcome associated with the type of consult, is a possible approach. “In healthcare, the question, ‘Was the infection resolved?’ is yes or no. With ethics consults, it’s not that easy,” says Kirk.

Another obstacle is that the skill set required to be a good ethics consultant is very different from the skill set required to perform data analysis. “If someone comes to ethics through philosophy or theology, they probably have zero statistics training and very little experience in quantitative analysis,” says Kirk.

While ethicists probably agree with the notion that it’s good to perform quality reviews, many have no idea how to accomplish it. “But that’s not insurmountable,” says Kirk. “It may be a stretch, but somebody in the organization is doing quality work and they can learn from that person.”

Without clear criteria to strive for, ethics is in danger of relying on a “feel-good approach,” says Kirk. “You just talk about things that are hard, and hope that afterward things are better. But you don’t have clear aims.”

Cases can be reviewed monthly, quarterly, or annually to get a general idea of whether consultants are meeting expected standards of practice. “Other approaches are finer-grained, and might delve into evaluation of individual chart notes written by consultants,” says Joshua Crites, PhD, a bioethicist at Cleveland (OH) Clinic.

Some ethics consult services have developed tools so evaluation can look for the presence of recommendations and ethical analysis. “A few services across the country are going even further to begin assessing the thoroughness of such analysis,” says Crites.

Little has been done to compare data across ethics consult services nationally. “As a result, quality assessment has largely been siloed, outside of efforts to ensure quality through the certification of individual consultation through a standardized process,” says Crites.

An added challenge: There is no consensus on the single best method to evaluate ethics consults. “The current methods we employ all seem to have drawbacks,” says Courtenay R. Bruce, JD, MA, assistant professor of medicine and medical ethics at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston. Some approaches and limitations include the following:

  • Documentation in the medical record doesn’t tell the whole story.

An ethicist can write a stellar note, yet have terrible interpersonal skills. “This ‘error’ would not be picked up through a chart review,” says Bruce. “Chart notes can only tell us so much about what occurred in a case.”

  • Debriefing sessions rely on ethicists’ willingness to criticize colleagues who often are present during the discussion.

“Out of a need to maintain respect and professional relations, clinical ethicists may feel obligated to be ‘nice’ to their colleagues who conducted the case,” says Bruce. This undermines the purpose of a rigorous review.

  • Spot-checking cases means many consultations aren’t evaluated.
  • Peer review, with ethicists watching colleagues conduct cases, makes the case prone to observer effects.

Bruce says the solution is for ethics quality improvement to include all these methods, supplemented with feedback from clinicians, patients, and families: “By using a combination of methods, you can identify the strengths and weaknesses of cases and consultants.”

Most markers of high quality in ethics consultation come from expert consensus, rather than from empirical data. “This is not surprising, given that ethics consultation grew largely organically out of, but separately from, healthcare delivery,” says Crites. Thus, the outcomes, structure, and processes of ethics consultation have largely been derived from within the practice itself.

This has resulted in a situation where defining and measuring quality is performed by ethics consultants themselves. “I think it would be more effective, in some ways, to have greater input from users — patients, families, and care providers — about what they believe would be most helpful from ethics consultation,” says Crites.

These data can then be used to determine what is meant by “quality,” and assess if the service is delivering consults that are high-quality in the eyes of those who utilize the consults.

The Cleveland Clinic’s ethics consult service surveys stakeholders to gauge their satisfaction with the ethics consult. “Our efforts have attempted to extend beyond simple satisfaction, such that we are trying to assess ‘value-oriented’ satisfaction,” says Crites. This is an attempt to evaluate, from the end-user’s perspective, what value was added to a patient’s care by including an ethics consultation.

“Data gathered about various types of satisfaction help ethicists see areas for improvement that may not have been as apparent through other methods of assessing quality,” says Crites.

Clinicians might want ethicists to help them handle similar ethical issues in the future, for example. A retrospective chart review wouldn’t reveal this, but asking clinicians, “How can the ethics consult service do things differently in the future?” might.

Conducting retrospective case reviews does allow ethicists to identify patterns of requests in specific areas of the hospital. “Ethicists can then plan targeted education in those units to improve care providers’ ability to manage ethical issues on their own,” says Crites.

SOURCES

  • Courtenay R. Bruce, JD, MA, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston. Phone: (713) 798-4929. Email: crbruce@bcm.edu.
  • Joshua Crites, PhD, Department of Bioethics, Cleveland (OH) Clinic. Phone: (216) 509-0451. Email: critesj@ccf.org.
  • Timothy Kirk, PhD, City University of New York-York College, Jamaica, NY. Phone: (718) 262-5316. Email: tkirk@york.cuny.edu.