Quality assurance (QA) in clinical ethics work comes with some unique challenges, and many in the field desire to do it better.

“Right now, I see a lot of interest in QA in clinical ethics. There are lots of people trying to figure out how to do QA at their own institutions,” says Thomas V. Cunningham, PhD, MA, MS, medical bioethics program director at Kaiser Permanente West Los Angeles Medical Center.

Approaches to QA in clinical ethics “are only beginning to be discovered and pioneered,” says Cunningham, lead author of a recent paper proposing that ethics move toward comprehensive quality assessment.1

One challenge is continued disagreement on how clinical ethics work should be evaluated. This makes data irrelevant outside a given institution. “There is no shared understanding of what ‘quality’ means with respect to the activities associated with clinical ethics,” explains Joshua Crites, PhD, a regional bioethicist and co-director of the Cleveland Fellowship in Advanced Bioethics at Cleveland Clinic.

Even published research on clinical ethics consults is inconsistent on this point. “When we really dug into the literature, we found that different authors seemed to mean different things when referring to quality in clinical ethics work,” says Crites, another of the paper’s authors. There are other obstacles to effective QA in ethics:

Ethicists often rely on case narratives instead of metrics that can be tracked and compared easily. “Detailed case narratives are crucial, but my view is that they aren’t sufficient alone,” Cunningham offers.

The main issue is that it is too difficult to analyze case narratives. To do so requires correlating case features with other data points, such as length of consults or patient satisfaction. “Historically, clinical ethics has been resistant to reductionist approaches to measurement using variables and mathematical analysis,” Cunningham observes.

This is changing, at least somewhat. “The field is now embracing a mixed methods approach, where narrative methods complement and co-inform reductive methods,” Cunningham adds.

When handling QA, most ethics services operate with limited resources — or none at all. “Institutions rarely resource clinical ethics work adequately,” Cunningham laments. There is no funding for the time and expertise needed for ethics QA.

One way to address this is by collaborating with the hospital’s QA department on issues that involve ethics. “Reach out to those people, learn about their work, and seek opportunities for collaboration,” Cunningham suggests.

At Kaiser Permanente West Los Angeles Medical Center, the quality department tracks “discordant events.” These are cases in which a patient receives care that does not concord with their stated preferences in an advance directive or POLST. “When the quality department is informed about a case with a potential discordant event, we work together to review the case,” Cunningham explains.

There is no standardization for ethics QA. Ethics QA is handled in many different ways, with widely varying methods and resources. “Different institutions track different measures of quality across different domains of work,” Cunningham notes.

This is problematic for an obvious reason: QA is all about making valid comparisons. “Since we lack standards of measurement, we lack the foundation for fair comparisons across time, across persons or groups, or across institutions,” Cunningham says.


  1. Cunningham TV, Chatburn A, Coleman C, et al. Comprehensive quality assessment in clinical ethics. J Clin Ethics 2019;30:284-296.