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A bioethicist interested in hospital-acquired infection policies could develop a better understanding of bacterial surveillance and contact precaution implementation through involvement in a nosocomial infection quality-assurance (QA) committee. Similarly, a bioethicist who wants to learn more about how health care providers discuss medical errors could become involved in an intensive care unit QA committee.
However, while QA committees often involve senior clinicians, health care providers, and administrators with specific interests or expertise in the QA area being assessed, bioethicists often lack a clear presence.
"Insofar as bioethicists are represented on these committees, it is more common that a member has separate training or a secondary interest in bioethics, as opposed to having a specific clinical or research bioethicist serve on the committee. There are, however, a number of potential benefits to bioethicists in joining QA committees," says Andrew Courtwright, MD, PhD, a physician at Massachusetts General Hospital’s Institute for Patient Care in Boston, MA.
Most hospitals have a center for quality and safety that serves as an umbrella organization for the QA committees of individual medical divisions, such as obstetrics and gynecology or pulmonary and critical care medicine, notes Courtwright.
"These committees, in turn, are often subdivided into specific clinic areas — perinatal care, disaster preparedness, or medical intensive care," he says. Ad hoc subcommittees may also meet to consider specific issues such as appropriate intubation thresholds or hospital bed allocation during pandemic flu.
"Relying on patient feedback, morbidity and mortality conferences, self-report from staff, and hospital data collection, subcommittees review patient outcomes and develop system-level policies to prevent or to address adverse events," says Courtwright.
Bioethicists can contribute to discussions about such topics as disclosure of medical error, policy responses to root cause analyses, and adverse event publicity and reporting. "The QA committee environment can introduce bioethicists to a number of clinical conversations that are often handled more abstractly in the medical ethics literature," adds Courtwright.
Developing collaborative connections to senior clinicians can foster an environment in which these clinicians are more likely to request clinical ethics consultation from their bioethicist colleagues. "Insofar as QA committee policies may impact clinical ethics consultation — for example, terminal ventilator weaning protocols or palliative sedation protocols — having a member with specific experience in these areas may be useful in developing policy," adds Courtwright.
The integration of bioethicists into QA committees may meet with some resistance from health care providers more accustomed to working solely with clinical colleagues. However, the committees can benefit by actively seeking bioethicist members. "Many QA projects straddle the border between quality improvement and human subjects research," says Courtwright.
Having a member with training in the Office for Human Research Protections requirements would help QA committees decide in advance whether to apply for a waiver of informed consent before embarking on a hospital-wide policy intended to change patient care patterns.
"QA committees are intertwined with the needs and expectations of patients, family, and staff, and are thus interconnected with values," says Marleen Eijkholt, PhD, LLM, a clinical ethics fellow at Alden March Bioethics Institute at Albany (NY) Medical College.
She says that participation of bioethicists in QA committees entails these benefits for the hospital:
• Bioethicists help to translate concerns of different stakeholders.
"By participating in QA, they help to ensure representation of the different stakeholders’ perspectives," she says.
• Bioethicists can contribute to the understanding of "good" and "bad" care as components of quality assessment.
For example, while physicians may want to pursue every avenue and technology for a patient, bioethicists may offer reminders that considering quality of life may call for limiting the amount of interventions for patients in defining quality of care.
"Understanding of these different perceptions may be time-consuming. The bioethicist is in a unique position to invest this time," says Eijkholt. "Similarly, bioethicists can broaden and enrich the understanding of effectiveness and efficiency in the process."
• Bioethicists can "build bridges" between patients, professionals, clinical areas, and management.
"Patients could be assured that they are heard on management level, while administrators will understand that their perspectives could be conveyed in the clinic," says Eijkholt.
• Participation by bioethicists enhances visibility of the service, and increases awareness about the function of the bioethicist in the hospital.
"Bioethicists are often faced with the preconception that we are policing,’" says Eijkholt. "Participation in these committees can help to debunk this myth, making us more approachable and accessible."
• Participation could enhance trust and validation in QA systems, on both the provider’s and the patient’s side.
"In order to build trust and optimize communication, familiarity with QA strategies and development is essential," says Eijkholt.