Administrators expect to see evidence that a clinical ethical program is worth supporting with financial resources. Yet many ethicists are unprepared for this kind of conversation, one that requires data for an effective response.
“Document as much as possible the benefit of ethics resources to clinicians, patients and families, and administrators,” advises William Nelson, PhD, MDiv, director of the Geisel Ethics and Human Values program at Dartmouth. Here are some common questions from hospital leaders:
• What are the role and function of the ethics committees? A yearly detailed report on the committee’s activities should be provided to institutional leaders, according to Nelson. The report should include the number and types of ethics consults; all ethics education provided to staff, community, and committee members; and institutional policies that the committee reviewed or drafted.
• Are ethics committee members knowledgeable and skilled? Have they received formal training? Ethics leaders can respond by talking about formal training programs in healthcare ethics, as well as the American Society for Bioethics and Humanities’ Healthcare Ethics Consultant-Certified program.
• Is the ethics committee assisting the organization in fulfilling its stated mission and values? Effective responses include any available data verifying the effectiveness of ethics consultations, Nelson offers. Results of post-consult assessments, feedback from focus groups, and suggestions for improvement from clinical leaders are some examples. “Existing tools, such as staff and patient satisfaction surveys, can be used to evaluate ethical alignment or the lack of it,” Nelson adds.
Ethicists also can note how their work prevents costs by proactively addressing moral distress and conflicts, thus preventing burnout and litigation. “It’s good to describe how the ethics program has moved beyond just a reactive approach, and instead, is using a preventive approach,” Nelson observes.
Most ethical conflicts are recurring, such as disagreements on medical futility. Post-consult reviews can determine if system changes are needed to prevent future conflicts, Nelson suggests. It also is relevant to talk to administrators about meeting their own ethical obligations based on the American College of Healthcare Executives’ Code of Ethics. “The ethics committee’s activities can assist the leaders in fulfilling various aspect of the required expectations,” Nelson explains.
Many hospital administrators asking about the “value” of ethics are thinking in terms of cost savings; in other words, monetary value. “This kind of value does not necessarily map onto the kind of value that should be the focus of ethics interventions,” says Jane Jankowski, DPS, interim director of the Cleveland Clinic Center for Bioethics. The authors of a recent paper advocated for a narrative approach to demonstrating value.1
However, ethicists must account for how their work contributes to the ethical delivery of healthcare. “The clinical ethics service should explicitly connect its work to the mission of the institution,” says Jankowski, one of the paper’s authors.
Administrators may be surprised at the scope of the ethicist’s work, and the multiple ethical challenges in a single case. “We are a weird bird in the hospital in that we do not produce RVUs [relative value units] or have clearly defined metrics set by regulatory bodies,” says Laura Guidry-Grimes, PhD, another of the paper’s authors and an assistant professor of medical humanities and a clinical ethicist at the University of Arkansas for Medical Sciences in Little Rock.
Hospital leaders understand data (e.g., length of stay, consult volume, or patient satisfaction scores). “While ethics consultation may have some indirect impact on these measures, they should not be the primary aim of our work,” Guidry-Grimes offers.
Discussions with hospital leaders can be difficult because of a lack of understanding of what ethics does. “Some ethicists have even reported being asked to find ways to be revenue-generating,” Guidry-Grimes reports.
Many healthcare positions do not bill patients or generate revenue, but are nonetheless part of assuring safe and high-quality healthcare, Jankowski notes. “Ethicists, just like everyone else in healthcare, are expected to uphold responsible stewardship of fiscal resources,” she notes.
Many other hospital departments can talk about how ethics contributes to patient-centered care. “Clinical ethics services might find amazing allies in unexpected places,” Guidry-Grimes says. Social workers, case managers, palliative care providers, psychiatrists, patient advocacy or patient experience offices, pastoral care, and legal counsel all are potential ethics advocates.
To make allies out of administrators, ethics should find ways to meet the needs of specific patient populations, Guidry-Grimes suggests. For example, the institution might be committed to growing its outreach to underserved patient populations in urban or rural areas. “An ethics team could offer to provide education on health literacy barriers in the informed consent process,” Guidry-Grimes says.
The process of resolving an ethical conflict cannot be quantified in dollars. “It may not necessarily be captured in metrics. However, narratives are quite powerful,” says Hannah I. Lipman, MD, MS, director of bioethics at Hackensack (NJ) University Medical Center. Bioethicists can demonstrate value by telling compelling stories about how a particular issue was addressed. “Ideally, the narrative shows how bioethics bring a variety of stakeholders together,” Lipman offers.
At Hackensack, bioethicists routinely provide ethics education on cases during ICU rounds. Recently, a resident identified an ethical issue in one of her cases, and consulted ethics. There was a conflict among surrogate decision-makers who disagreed with an order not to attempt resuscitation.
“During the consultation, the bioethicist identified additional opportunities for education,” Lipman recalls. These included conflict resolution techniques, the hierarchy of surrogates when the family dynamics are complicated, and good communication practices for conversations about do-not-resuscitate orders. “This shows how the various activities of bioethics are interconnected,” Lipman notes.
The resident knew to consult bioethics because she had learned from the bioethicist on rounds. Then, the bioethicist ensured the lessons learned from an individual case were addressed on a systems level.
This kind of story brings home the “value” of ethics to hospital administrators. “We should be in the habit of sharing these narratives, and be ready to unpack in detail the specific contributions we made,” Lipman says.
- Guidry-Grimes L, Warren M, Lipman HI, et al. Clarifying a clinical ethics service’s value, the visible and the hidden. J Clin Ethics 2019;30:251-261.