EXECUTIVE SUMMARY

Ethics services often find it challenging to demonstrate financial impact on the organization due to lack of data and the preventive nature of many interventions. Some approaches include the following:

• invite hospital administrators to round with the ethics team;

• regularly report on successful cases;

• ask influential leaders to advocate for ethics.


"Because of ethics, we saved $10 million in not having to provide futile care in this hospital, five nurses have not left this hospital in search of other jobs due to moral distress, and medical malpractice insurance expenses were cut by 20%.”

A good ethics consultation service might indeed have accomplished all of this and much more, but solid proof is elusive. “It’s very difficult to prove that because of ethics, something bad did not happen,” says John D. Banja, PhD, a medical ethicist at the Center for Ethics at Emory University in Atlanta.

For instance, costly burnout and staff turnover can be prevented if ethicists address clinicians’ moral distress with consults and education. “But if administrators are truly fixated on ROI [return on investment], you’re up against a wall, because that’s going to be hard to show with conclusive data,” says Banja.

Hospital administrators are used to basing their decisions on certain kinds of metrics, as opposed to anecdotal evidence. “It’s always a challenge for ethics folks to show a return on investment to the kind of leadership that is singularly or narrowly fixated on the bottom line,” says Banja.

Nonetheless, there often is a need to justify resources for ethics. David A. Fleming, MD, MA, MACP, co-director and scholar at University of Missouri’s Center for Health Ethics in Columbia, notes, “As with any clinical service, ethics consultation teams and committees typically serve at the pleasure of hospital systems.”

Fleming adds that ethics services exist, for the most part, in response to a 1992 Joint Commission requirement that all healthcare organizations establish a policy and mechanism to address ethical concerns. How that is manifested is up to each healthcare system, ranging from minimal to robust.

“The more value realized from clinical ethics consultation, the greater resources will be invested in sustaining and growing those services,” says Fleming.

Data supporting the need for clinical ethics consultation services tend to be more qualitative than quantitative. Data often come from surveys of patients, families, and clinicians who were involved in ethics consults. “Satisfaction data is important to know if we, as ethicists, are well-received and helpful,” says Fleming. “More helpful, but difficult to find, would be data reflecting actual clinical outcomes.”

It seems obvious that ethicists positively affect quality of care, costs of end-of-life care, allocation of resources in making treatment choices, and moral distress. But demonstrating it with data is another thing entirely. On the other hand, other hospital departments may already be collecting data that can be useful to ethics. Risk managers and quality improvement are two examples. “The sensibilities and concerns of all these areas are going to come together more and more, and ethics is definitely going to be right in the mix,” predicts Banja.

In Fleming’s experience, moral discomfort of team members, where it exists, is helped by ethics consultation. “This is based on the feedback I get from the teams in the hours and days following the ethics team’s input,” says Fleming. This is especially true in complex cases where emotions are running high and there is ambivalence as to what direction to take.

“In end-of-life cases, where futility is determined and withholding and withdrawing treatment is being considered because it is deemed ineffective by the team or unwanted by the patient, decreased cost and length of stay are clearly reduced,” adds Fleming.

Data on cost, quality, satisfaction, length of stay, and utilization of services can serve to convince skeptical hospital leaders of the financial effect of ethics. “The value of ethics services can be determined by measuring these variables in relations to the consult itself,” says Fleming. The training, skills, and attitudes of staff; demographics of resource allocation; and personal experiences of the patient, family, and team all can be taken into account.

“Objectively determining the value of ethics consults can be done through a QI [quality improvement] project,” adds Fleming. For instance, outcomes could be compared in similar clinical situations that have and have not involved an ethics consult. Some possible variables to analyze include cost, rate of hospice referral, days spent in the ICU, patient/family satisfaction, and provider satisfaction.

Established, data-driven QI and patient safety mechanisms can be of great help. “Clinicians, administrators, and clinical ethicists can work together with a shared goal of improving quality outcomes and decreasing unnecessary cost,” says Fleming.

Lots of Accessible Data

Ethics consultations favorably affect a hospital financially as a cost-reduction mechanism, says Gavin Enck, PhD, director of clinical ethics at Integris Health in Oklahoma City.

“Although ethics committees and a consultation service are not driven by financial considerations, evidence suggests resolving conflicts and patient-provider disagreements, as well as identifying goals of care and values, reduces costs relating to unnecessary care,” says Enck.

Such data incentivize hospitals to invest resources in their clinical ethics programs. Ethicists typically turn to hospital risk managers as a potential source. “While risk management is important, this overlooks a lot of accessible data,” says Enck.

Electronic medical records have generated an immense amount of data, some of which can be put to use by ethics. “The key for the ethicist is to connect and establish relationships with QI, informatics, IT, and financial services,” suggests Enck.

Working with these other services, ethicists can determine which metrics in a consultation are measurable and can be tracked. “Once measurable metrics are identified, this group can examine the way these consultations affect patient care and quality,” says Enck.

Examples include length of stay, length of stay in ICU, length of stay on mechanical ventilation, readmissions, grievances filed, patient and staff satisfaction scores, and staff turnover.

Data on what occurred after ethics consultations also can be revealing, says Enck. Some areas to look at: patient code status changes, creation of advance care planning documents, stopping or starting of intensive interventions, identification of goals of care or surrogate decision-makers, and patient transfers to other hospitals.

The next step is to compare these measurable metrics against similar patient populations in which ethics consults did not occur. “This comparison should indicate, even if broadly, the financial impact of ethics consults,” says Enck.

Ethics Team Is Essential

Some services in medicine are central to meeting the core mission of healthcare, and therefore should not be required to demonstrate ROI or cost-effectiveness, argues Maria Silveira, MD, MA, MPH, associate director of research at University of Michigan’s palliative care program. Silveira also is a clinician scientist at VA Ann Arbor Health System’s Geriatric Research Education and Clinical Center.

“Those services should be provided without consideration of a price tag,” says Silveira. “No one questions the ROI for the emergency room, the hospitalists, or the general surgeons.”

These services are necessary in order for a hospital to be a place with the capacity necessary to handle most needs related to human illness and suffering. The same is true of ethics services, says Silveira: “I would argue that an ethics service is required in any healthcare setting where you have vulnerable patients, high stakes, and any need for shared decision-making.”

Banja agrees that it’s essential for every hospital to have staff with ethics expertise to help clinicians sort out all kinds of thorny issues. As just one example, physicians and nurses often are unclear on what family members can demand, and what duties the healthcare provider actually has. “It’s remarkable that we don’t spend enough time teaching them what their obligations are, and when they can say no,” say Banja. When inevitable end-of-life conflicts arise, “there can be all kinds of nuances and subtleties that the law has not covered and that perplex doctors and nurses,” says Banja.

For an ethics program to succeed, says Silveira, “you need leadership to buy into the idea based upon principle alone.” She suggests the following approaches:

• inviting hospital leaders to round with the ethics team, to see the work they do firsthand;

• compiling a binder of narratives from cases the ethics service successfully navigated, including quotes from appreciative clinicians and families. Then, use those narratives to report “cases from the field” to relevant leaders in the organization on an annual basis;

• reporting programmatic costs as a percentage of the hospitals’ annual operating budget.

This shows administrators how little is actually spent for the service. “In most cases, ethicists are volunteers — though I believe they shouldn’t be,” notes Silveira.

Alexander A. Kon, MD, FAAP, FCCM, clinical professor of pediatrics at University of California, San Diego School of Medicine, says most healthcare ethics consultation services would never be able to demonstrate financial viability alone. Ethics consultants don’t bill for their time. Kon says that “cost savings to the organization are modest at best,” and don’t come close to covering consultants’ salaries.” “So I don’t think arguing that the service is self-supporting is a good tack.”

A better approach, says Kon, is to view ethics through the same lens as other important, non-financially independent services. For instance, child life specialists on pediatric wards don’t generate much income or save significant costs. Yet physician and nursing leadership are advocates for the program.

The same holds true for ethics. “What the ethicist has to do in order to maintain value in the hospital is to get nurses and doctors on their side,” says Banja. A grateful physician might tell the hospital CFO, for instance, “The ethicist helped us to navigate this incredibly awful case. There was no question in my mind that we would have had a much harder time without the ethicist.”

There are clinicians who are concerned about ethics in every hospital. “More than you think are very concerned about the ethical dimensions of relationships with patients,” says Banja. Those are the individuals the ethicist has to keep in close contact with and recruit as champions of ethics.

Kon recommends the following leaders advocate for ethics:

• leaders from medicine, especially in high-revenue areas such as surgery, ICU, and obstetrics;

• nursing leadership;

• risk management/legal affairs;

• representatives on the hospital’s family council;

• major hospital donors.

“When such leaders come together and tell the hospital CEO that they need the ethics consultation program in order to appropriately care for patients and run the hospital, the CEO tends to listen,” says Kon.

SOURCES

• John D. Banja, PhD, Center for Ethics, Emory University, Atlanta. Phone: (404) 712-4804. Email: jbanja@emory.edu.

• Gavin Enck, PhD, Director of Clinical Ethics, Integris Health, Oklahoma City. Phone: (405) 945-4558. Email: gavin.enck@integrisok.com.

• David A. Fleming, MD, MA, MACP, Co-director and Scholar, MU Center for Health Ethics, University of Missouri School of Medicine, Columbia. Phone: (573) 882-2738. Email: flemingd@health.missouri.edu.

• Alexander A. Kon, MD, FAAP, FCCM, Clinical Professor of Pediatrics, University of California, San Diego School of Medicine. Email: kon.sandiego@gmail.com.

• Maria Silveira, MD, MA, MPH, Geriatric Research Education and Clinical Center, VA Ann Arbor Health System. Phone: (734) 936-6183. Email: mariajs@med.umich.edu.