Ethics services are finding that the number of consults requested does not tell the full story of their workload.
“The ability to clearly demonstrate an ethics program’s value has been a persistent challenge for our field for some time,” says Jordan Potter, PhD, HEC-C, supervisor of the Wellstar Fellowship in Clinical Ethics and a clinical ethicist at Wellstar Health System.
Wellstar’s ethics service recently started to track its activities outside of consultations.1 “Our research examines the impact of systematically tracking other vital functions of ethics programs,” Potter explains.
This includes internal education, orientation presentations, external education (conferences, seminars, and invited talks), publications, grants, committee work, rounding, policy development, and medical resident/fellow rotations with the ethics consultation service. “The quantitative criteria for each non-consult ethics activity that we track varies,” Potter reports.
The three main quantitative criteria are number of sessions, number of attendees, and time spent. For example, internal education, orientation presentations, and external education are tracked in two ways: by the number of sessions and the attendees for each session. “For activities like committee work and rounding, we track both the number of sessions and the time spent,” Potter says.
Quantifying all these “non-consultation ethics activities” gave hospital administration a better picture of an ethics program’s value, enough to devote more resources to it. Currently, Wellstar’s ethics program includes five clinical ethicists and two postdoctoral clinical ethics fellows. They recently used the data to justify adding a sixth full-time clinical ethicist.
Data on internal education and interdisciplinary rounding in particular offer “tremendous value” for the organization, says Susannah Lee, JD, MPH, a former clinical ethics fellow at Wellstar Health System. “These activities are a way to potentially increase ethics consult volume, as well as ensure earlier identification of cases in need of an ethics consult,” Lee says.
Earlier ethics involvement can positively affect important metrics such as length of stay. There also are some intangible benefits. “More ethical awareness among caregivers leads to a better overall ethical culture within the institution, which benefits everyone,” Lee notes.
When ethicists set out to quantify their work, they find there really is no standard method. “The distinction between a formal and informal consultation varies across different institutions,” says Trevor M. Bibler, PhD, assistant professor of Medicine at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston.
This matters because formal consults usually are tracked, while informal conversations are not recorded in any way. “It gets back to the question of value,” Bibler says.
The value of a formal consult is clear, because ethicists can point to something concrete — a patient, a clinician, or unit received help. It is harder to pinpoint the value of a 20-minute presentation during a nursing steering committee meeting. “There is not a close connection between the ethicist’s action and quantifiable outcomes,” Bibler explains.
Questions such as “Did it change anyone’s practices?” or “Did it affect patient care in any direct way, or even an indirect way?” usually are impossible to answer. Still, quantifying all the work ethics does is important for many reasons. “The institution might look at the data for quality improvement efforts and comparisons with other consultation services,” Bibler says.
The main reason ethics consults are tracked is because electronic health records are set up to capture those data. “Unless they create one, ethics services do not have a similar system for collecting real-time data on other work they do,” says Laura Guidry-Grimes, PhD, an assistant professor of medical humanities and bioethics and a clinical ethicist at University of Arkansas for Medical Sciences.
Creating a database to do that requires expertise and resources. “The time that ethics services have is often constrained due to high consult volume, not enough staff, and limited FTEs,” Guidry-Grimes observes.
The concern is that without good data, it can falsely appear the ethics service carries little value. “This misperception can directly translate into diminished support from leadership,” Guidry-Grimes says.
That could mean less funding or no invitations to work on important initiatives (e.g., COVID-19 pandemic response). In reality, many ethicists spend most of their time performing all kinds of tasks that benefit the institution: educating staff and trainees, debriefing after difficult cases to prevent burnout, and developing policy. “Any one of these could actually take up more time than consults in any given week,” Guidry-Grimes notes.
The solution? “Ethics services need protected time to collect these data into a reliable system,” Guidry-Grimes offers.
Spreadsheets in a cloud computing system (if protected health information is not involved) are one possibility. “REDCap is another system that has a mobile option that can help collect data from ethicists at the time of an activity,” Guidry-Grimes suggests.
For instance, ethicists could log in immediately after giving a grand rounds talk to record the topic and estimated number of attendees. The same could happen if night staff ask for a moral distress debrief. Ethicists could log how many people were part of the discussion and what general themes emerged.
The challenge is to make all these data meaningful. “That requires even more time — for interpretation, organization, and presentation of the data,” Guidry-Grimes explains.
Once “what ethics does” data are obtained, there are many potential uses. Guidry-Grimes offers these examples:
- Internal quality improvement of the ethics service. Ethicists might learn some consultants hold family meetings all the time, but others hardly ever do. Similarly, ethicists could find out which units or providers never request consults. “This may indicate the need for increased visibility, or investigation of consult barriers,” Guidry-Grimes notes.
- Shed light on issues related to organizational ethics. For example, the ethics service may discover an increase in moral distress debriefs and consult requests related to partial code status. “This discovery could prompt a bigger discussion,” Guidry-Grimes says. Such a discussion could reveal a problematic hospital policy, or the need to alter the medical record system to clarify medically and ethically reasonable code status options.
- Demonstrate the true range of ethicists’ work. “Administration can view these data as evidence of how the ethicists are serving the institution, and the need for expanded support for their work,” Guidry-Grimes says.
Ethicists at University of Rochester (NY) Medical Center are engaging in ongoing discussions about how to document all their work. “This is a topic that some of us on my team, and in the world of bioethics in general, recognize as something that needs more attention,” says Marianne C. Chiafery, DNP, PNP-BC, a nurse practitioner and clinical ethicist.
Part of the reason is the ethics field is evolving. “We are figuring this out as the field grows. It’s not a bad problem to have, since the growth of the field of bioethics is a positive development in healthcare,” Chiafery observes.
Many hospitals work with few ethicists, most if not all of whom work in other full-time roles. “It is rare to find anyone who does solely ethics consultation work,” Chiafery reports.
Informal “curbside” consults and nursing ethics huddles are not documented; only formal consults are. “Recently, our medical director had the opportunity to see a list of all that is done in the division, and he was surprised. We do not ‘toot our horn’ enough,” Chiafery recalls.
The information came up in an unexpected way, when the clinical director of ethics retired. For the job posting, he listed all the activities the role encompassed. “That’s when the depth and extent of his work was made known to others outside of our group,” Chiafery notes.
Noon conferences, spontaneous education provided to bedside staff, presentations during staff orientations, phone calls from affiliate hospitals, debriefings, and in-services all happen on the ethicist’s own time. “Not everyone is aware of these efforts,” Chiafery laments.
This makes it hard to justify hiring more staff to join the ethics service. “Until we quantitively demonstrate the amount of work being done, and what is not being done due to time and resource limitations, we will not be able to expand services within a care setting,” Chiafery acknowledges.
- Lee SW, Potter J, Matsler JS, Shields S. Demonstrating value through tracking ethics program activities beyond ethics consultations. J Clin Ethics 2020;31:268-276.