AMA's Ethical Force program aims for measures

"Increasingly, physicians and managed care organizations are being held accountable for quality of care based on the processes and outcomes of medical care and patient satisfaction. Yet high-quality care delivery involves more than good technical quality and acceptable customer service — it also means upholding high ethical standards."

— AMA web site literature on the Ethical Force Program

The mission of the American Medical Association's Ethical Force Program is to develop performance measures for ethics.

By taking domains of quality care and breaking them down into manageable components or activities that can be measured, yet still support the overall goal, the Ethical Force Program seeks to make it easier for health care institutions to heed the contemporary call to bring measureable goals — and most importantly, measurable outcomes — to health care.

"The issue that we're having to address now is that there's a lot of people who really buy this notion that 'if you can't count something, it doesn't count,'" says Matthew Wynia, MD, MPH, FACP, director, The Institute for Ethics, at the AMA in Chicago. "And as a result, the things that people are going to pay for are going to be things that you can count."

The bottom line, Wynia says, is, "If we can't figure out a way to monitor the ethical environment of a health care organization, then that's what will suffer."

Unlike whether a patient gets a flu shot or has a scheduled mammogram, it's not as simple a matter to determine if a physician really listened to a patient or communicated in a way the patient could understand so that he or she, for example, understood how to take medication as prescribed.

Recognizing that, the Ethical Force Program was first considered when the AMA began expanding its ethics group in the late 1990s in order to study different areas of health care and to develop practical tools that both hospitals and large group practices are using today, Wynia says.

"When the AMA decided to really re-commit to building the ethics group here, they brought in several of us who felt like the AMA did a terrific job of speaking to the patient-doctor relationship, and that our Code of Ethics really focused on the doctor-patient relationship, but that ethics in the health care system was so much broader than that," Wynia tells Medical Ethics Advisor.

A lead into the formation of the Ethical Force Program was the quality improvement movement, he says.

"The thing that we saw happening was a lot of interest in measuring how physicians were performing, which makes perfect sense," Wynia says. "But you have to realize, of course, that doctors work in organizations, and organizations can make it harder or easier for physicians to perform up to their ethical responsibilities."

So, enter the discussion of how organizations might do a better job of supporting quality health care, as well as physicians focused on quality. Part of that conversation and thinking was to focus on how to better understand how to measure performance of physicians and organizations, he says, but also to determine "Who has responsibility for what?"

The program's components

The Ethical Force Program has about 22 members on what it calls an oversight body, which according to the AMA is "responsible for selecting topics for performance measurement development as well as reviewing and approving all research programs and products."

Among those on the oversight body are representatives from The Joint Commission, the American Nurses Association, the National Institutes of Health and the National Committee for Quality Assurance.

"Our sense at the beginning was that we wanted patients at the table, we wanted providers, meaning provider organizations, so — health plans, hospitals," Wynia says. "We wanted doctors, nurses, and we wanted purchasers, so employer groups and so on."

Those categories, he said, have "remained the big four."

The agency is charged with selecting specific, broad topic areas for performance measurement development. For example, the Ethical Force Program's most recent topic of study was patient communication.

That broad topic can be broken down into "content areas," which Wynia says some in the ethics field might also refer to as "domains."

The program tends, however, to think of domains as larger, he says. So, "effective communication is the domain." Within any given domain, there are then a number of content areas for specific attention.

For example, patient communication can be dissected from this very broad topic down to steps to raise the health literacy level of patients. Program members can do this by asking a series of questions that become more and more pointed toward a specific action to take, with an expected outcome that could be measured.

Tools for hospitals

The Ethical Force Program offers "toolkits" for such providers as hospitals and large physician group practices that may be looking for ways to improve the ethics environment of their institution, facility or practice.

"We've been field-testing these for the last three years, and so we actually have a set of hospitals and larger group practices that are using these toolkits in an iterative fashion….They're doing quality interventions to see if they can improve their performance," Wynia says.

He says one of the advantages of breaking down domains into content areas is that a hospital might find that it, for example, may get an A-plus on language services, but the facility's signage isn't very good.

Many of the needed improvements institutions learn by using the toolkits are quick fixes, while others are more costly and more systemic in nature. In one example, one of the sites has a large number of Spanish-speaking patients. And while it was determined that the site, or facility, offers very good interpreter services, there was one small problem. It was determined through a survey that 30% of the people who used that facility thought interpreter services were an additional cost.

So, the next step that the facility took was to distribute flyers and put up posters letting patients know that interpreter services were offered at no charge to the patient.

The entire approach includes a self-assessment tool, or patient survey, a staff survey of both the clinical staff and the non-clinical staff, a leadership survey, and a policy checklist that "looks at the whole organizational environment and what policies are in place," Wynia says.

All of those components are analyzed by members of the Ethical Force Program, and a Feedback Report is provided to a site, or facility.

While the toolkit can be used completely by a institution or practice on its own, some of the components can be analyzed by members of the program for a fee.

"We have a lot of data now from sites around the country, and so if you want to see how you're doing in relation to others, then we have a lot of ideas that we have [gathered] over time that address different deficiencies that you might find," Wynia says.

What hospitals and practices tend to like about the toolkits is that the allow them to focus, and they give the users "a way to measure and find out whether what you're doing is making a difference in the patients' experience of care."

"I think almost everyone these days does some kind of a patient satisfaction survey, and this is a little different, because it involves . . . a 360-evaluation," Wynia says. "So, you really, I think, get a much better understanding of the climate of the whole organization."


For more information, contact:

  • Matthew K. Wynia, MD, MPH, FACP, Director,The Institute for Ethics, American Medical Association, Chicago. E-mail: