The VA leads change toward IntegratedEthics approach

"Throughout our health care system, VA patients and staff face difficult and potentially life-altering decisions every day — whether it be in clinics, in cubicles, or in council meetings. In the day-to-day business of health care, uncertainty or conflicts about values — that is, ethical concerns — inevitably arise." — IntegratedEthics: Improving Ethics Quality in Health Care (U.S. Department of Veterans Affairs monograph)

Ethical questions, concerns and issues probably are part of most health care providers' daily lives — from physicians to nurses to risk managers and institutional executives.

Recognizing this, the Department of Veterans Affairs, which manages the largest health care system in the United States, took on an initiative designed to raise the bar of ethics quality, and therefore the quality of health care delivered, throughout the VA health care system.

The result: IntegratedEthics — a program rolled out to the VA's 153 facilities since May 2007, and the VA's Ellen Fox, MD, chief ethics in health care officer at the VA's National Center for Ethics in Health Care, believes that the organization is, indeed, setting a new standard.

"When we first began to develop this, we developed the conceptual approach and communicated the ideas related to integrated ethics to our ethics community," Fox recalls. "And people were very excited about the ideas, particularly the idea that a piecemeal approach to ethics really doesn't adequately meet the challenges that employees face, and that to be truly effective, an ethics program must do more than just respond to ethics questions on a case-by-case basis."

The effort to establish standards for both ethics consultation and ethics consultants is a point of much discussion in the health care community currently. For example, the American Society of Bioethics and Humanities has an initiative underway to establish core competencies for ethics consultants

To have an effective program, Fox says you really have to address "the issues more comprehensively and systematically," which includes the idea that an "ethics program needs to foster an organizational environment and culture that makes it easy for employees to do the right thing."

The program in concept

"First, let me say that I don't think that there's anything about IntegratedEthics that doesn't apply to every health care system . . . Every health care organization has its own mission, its own unique characteristics, and the VA is no exception . . ." Fox says.

However, while the VA is different in that it is a government institutional system designed specifically to serve veterans of U.S. military service, "I think in terms of what we're trying to achieve with IntegratedEthics — it's really the same thing that every other health care organization is trying to achieve," she says.

The greatest challenge with this initiative, Fox says, is that "really what we're trying to achieve here is a fundamental culture change."

The image that the VA uses to describe the underlying concept of IntegratedEthics is that of an iceberg.

"That is really the symbol that we use now to represent the whole program — the idea that what you see — the things that are most visible in terms of ethical practices . . . represent only the tip of the iceberg."

As Fox says, most people "don't get up in the morning and say, 'I'm going to do something ethically problematic.'"

"Everybody wants to do the right thing, but you're powerfully influenced by the systems and processes and the environment and culture in which you work every day, so in order to influence ethical practice, which is what we believe ethics programs should be about in a health care organization, you really need to target directly not only the individual decisions and actions, but perhaps more importantly, the systems and processes and the organizational culture," Fox says.

This approach — using preventive ethics to target systems and processes "through a quality improvement approach," as well as the ethical leadership component — are what make the program unique, Fox says.

Asked if she considered IntegratedEthics a possible model for other health care institutions, Fox declares, "Oh, absolutely."

In developing the program, the VA leaders relied on experts from around the country and those outside the VA. The development process also included an extensive review guided by an advisory board for "certain aspects of development."

"So, yes, all along we were aware of the fact that we would be going well beyond what had already been done in the field, and therefore felt a responsibility to make sure that it was equally applicable to other health care systems."

Five years of tool development

When initially set forth, the ideas that are the backbone of the IntegratedEthics approach resonated with employees, Fox says, but the employees really didn't know how to create the change required.

"We went back and realized that we had to put a lot more resources and time and expertise in developing practical tools that would allow people to translate the vision, and the excitement they had about these ideas, into reality on the ground," Fox says, noting the year as 2001.

The VA spent five years developing tools that are built around the three building blocks of the Integrated Ethics model:

  • ethics consultation;
  • preventive ethics;
  • ethical leadership.

Those tools are available on the VA's web site.

Because, the VA has "resources that an individual health care system wouldn't have," the department was able to "develop a very comprehensive package to support this whole initiative," Fox says.

Ethics consultation facet

According to Fox, "Another really important aspect of IntegratedEthics is that we are standardizing processes and developing concrete standards for how we do business in our ethics program, so we've put a lot of energy into insuring the quality of ethics consultation, developing standards for ethics consultants . . . "

So, she says, although other health care institutions and facilities often conduct ethics consultations, the VA program, "establishes a standard and really raises the bar on ethics consultation, as well."

The VA model also adopts the same standards for ethics consultants as those set forth by the ASBH.

While there is a great deal of anecdotal evidence that the IntegratedEthics model is also achieving the stated objectives and goals of its own "Business Case for Ethics" (see the VA web site), it's still too early to have gained actual performance measures.

Results to date

Its own "Business Case for Ethics" suggests that a strong ethics program "can reap many concrete benefits for a health care organization," including:

—increasing patient satisfaction;

—improving employee morale;

—enhancing productivity;

—conserving resources/avoiding costs;

—improving accreditation reviews;

—reducing ethics violations;

—reducing risk of lawsuits;

—sustaining corporate integrity;

—safeguarding the organization's future.

All 153 facilities in the VA system were charged with implementing certain standards related to the IntegratedEthics model by the end of FY 2008, which ended Sept. 30. With this charge, the facilities had 13 possible points that they could score for the implementation. A passing score was 9 points. Of the 153 facilities, all but one facility received a passing score, Fox says.

Fox also notes the result from a year-long demonstration project completed in 2006 in which 25 facilities participated.

"We did exit interviews with those 25 facilities, and 100% said they thought the Integrated Ethics program was worthwhile and would significantly improve ethics quality in their health care organization," Fox says.

Also, an IntegratedEthics staff survey was completed in August and September of this year for the first time, involving a database of 99,000 responses from the all-employee survey, Fox says.

"As you can imagine, there's tremendous opportunity there for us to be able to correlate the ethics-related data to other quality data in our organization and really get to what's going on in an individual facility," she says.

And her overall perspective is this: "The fact that [this program is] resonating suggests that we're filling a need."


For more information, contact:

  • Ellen Fox, MD, Chief Ethics in Health Care Officer, the National Center for Ethics in Health Care, Department of Veterans Affairs, Washington, DC.