VHA model to bring ethics into "organizational mainstream"
Assessment of patient care includes ethics quality
The idea that health care quality encompasses ethics, as well as technical and service quality, was the motivation for the IntegratedEthics (IE) approach that was rolled out in 2000 by the Veterans Health Administration (VHA)'s 153 medical centers. Fourteen years later, the program is still evolving.
"We realized that the traditional U.S. ethics committee design was not suited to achieve the ethics quality concept," says Melissa M. Bottrell, MPH, PhD, chief of the VHA's IE program.
If a patient's surgery was perfectly executed from a technical perspective and the patient was satisfied with the care received, but the patient was misinformed about the procedure, then that patient's care lacked ethics quality, for example.
"At the time we began developing IE, articles in the literature noted that ethics committees often functioned in isolation, and were not well-connected with other parts of the organization," Bottrell says. "They tended to be reactive and crisis-oriented."
As a result, unaddressed ethical concerns cause moral distress, patient dissatisfaction, staff burnout, and poor quality care. "We recognized that ethics is something that can be managed, measured, and systematically improved," says Bottrell.
The IE program is structured around three core functions: ethics consultation, preventive ethics, and ethical leadership. These changes were made:
- Detailed standards were introduced for ethics consultations.
- A sophisticated electronic documentation system was created for ethics consultation. "This enables tracking and trending of ethics consultations across our large system," Bottrell says.
- A tool was created to assess knowledge and skills of individuals who provide clinical ethics consultations, based on the American Society for Bioethics and Humanities' competencies.
- "Preventative ethics" was introduced to address ethical issues more proactively on a systems level. This includes routine activities performed by ethics committees, such as periodic policy updates, ethics education for staff, and accreditation readiness.
"Its main focus is on quality improvement cycles, which are time-limited interventions targeted to address specific ethics quality gaps," says Bottrell. "These cycles are a key IE innovation."
Traditional model unable to provide leadership
The role of the ethicist has traditionally been to respond to requests by health care professionals for assistance in finding a resolution for ethical problems, conflicts, and dilemmas they have been confronted with, says Evelyne Shuster, PhD, former hospital ethicist at the Philadelphia VA Medical Center. Generally, these involve end-of-life care, the use of life-sustaining technologies, ethical questions about life and death, and respect for patients' wishes and autonomy.
"American bioethics has traditionally been confined to ethics committees and monthly meetings," says Shuster. "This model of American bioethics is not what the founders had envisioned."
American bioethics was to be richer in its diversity than traditional medical ethics, she explains, and enriched with the knowledge and understanding of the underlying forces that shape people's lives, the environment, values, and behaviors.
This vision of bioethics was not realized, as American bioethics evolved into a discipline that dealt with procedural and regulatory questions, and the "nuts and bolts" of medical decision making. "Today's reductionist ethics model cannot provide leadership on issues that know no organizational or national boundaries," says Shuster — such as weighing in on the need for universal access to affordable health care.
The VHA's IE program represents a "fundamental departure" from the traditional approach to ethics in health care organizations, says Shuster. "It represents an expressed will to identify the foundational forces that shape values, drive decision making, and affect environment and culture," she says.
Here are some examples of system-wide issues the IE program is addressing:
- how well the organization promotes collaborative decision making between clinicians and patients;
- how well the organization addresses death and dying issues;
- ethical leadership — how well behaviors and activities by medical center directors and their associates promote high ethical standards that apply to all activities within the organization.
The IE program is designed to move ethics into the "organizational mainstream," says Bottrell. "This requires more than simply managing the work of ethics consultation, preventive ethics, and ethical leadership," she adds. "It is an integrative structure with clear lines of accountability."
Each IE program has a program officer who acts as the executive director for the program. The program's work is directed by an IE council, which may include the chief of staff, chief fiscal officer, patient safety officer, human resources director, information security or privacy officer, compliance officer, or nursing representatives.
The council ensures that the IE program achieves timely completion of two measurement tools designed to provide an overall assessment of ethics quality. These are the IE facility workbook, a self-assessment completed annually by facility teams, and the IE staff survey tool, administered to all employees every other year.
"Both tools help facilities evaluate current ethics quality, identify strengths as well as opportunities for improvement, set goals, and develop quality improvement plans," says Bottrell.
Continued challenges to success
Bottrell says the biggest challenges for the IE model are the same ones experienced by all ethics programs. "Improving quality and changing practices requires resources — especially staff time," she says.
Changing organizational culture takes leadership engagement and long-term commitment by leaders at all levels of an organization, in order to foster an ethical environment and culture, notes Bottrell.
"With the U.S. health care system undergoing major restructuring, it will be important to keep the focus on ethics," she says.
Consistent with the adage "you can't manage what you can't measure," IE establishes clear standards for ethics quality, along with validated measurement tools. "This may itself be the most important IE achievement, since experts have been calling for the establishment of validated ethics measures for many years," says Bottrell.
Metrics do matter, says Shuster, but satisfying demands for accountability is not the goal. "The IE council must be willing to recognize that good measurements and box-checking ethical compliance are not proxies for ethical excellence," she says.