What is keeping hospital administrators up at night? This is a question ethicists should be asking, according to Jason Lesandrini, FACHE, LPEC, HEC-C. “We fail to do this, oftentimes, in the ethics world.”
Ethicists already know their work is good for patients, families, and providers. “But it is crucial for the development and growth of ethics programs that ethicists and ethics directors think about how the work they do impacts the broader health system,” argues Lesandrini, assistant vice president of ethics, advance care planning, spiritual health, and language access services for Wellstar Health System.
Burnout, retention, and employee engagement — all top priorities at virtually all hospitals — can be affected by ethics consults where conflicts are resolved and moral distress is alleviated. Even so, some ethicists reject the idea of taking hospital metrics into account. “You get a lot of pushback from ethicists, that ‘We don’t want to become metrics-chasers,’” Lesandrini says. “I just don’t think that’s a good stance to take.”
The fact is the work of ethics aligns with many issues that are top of mind for hospital leaders. “We need to think about, ‘How do we measure that?’” Lesandrini suggests.
The challenge is for ethicists to connect metrics to their work. “This isn’t about chasing a metric for the system. It is about making the connection between the work already done and work that matters to healthcare leaders,” Lesandrini stresses. For example, there may be a decrease in patient complaints, or an increase in patient satisfaction. Even without hard data, ethicists can “tell the story” of how they are meeting the hospital’s mission by describing a particular case.
A good example is a case where a patient does not present with a surrogate. Ethicists can identify the need for a surrogate during ethics rounds and facilitate referrals to care coordination for a court-appointed guardian. In a case like that, the ethicist’s actions prevented an extended length of stay and prevented moral distress due to staff providing potentially inappropriate care.
Ethicists also can offer “evidence” in the form of post-consult comments made by clinicians. Nurses may state, “I was thinking about leaving the organization, but I’m reconsidering.” For hospital administrators, that feedback speaks directly to the organization’s efforts to alleviate the nursing shortage.
Creating an effective way to track ethics data and analyze it is essential, Lesandrini underscores. Ethicists might accomplish this with spreadsheets or another tool. It might require a program administrator to spend an hour or two to capture data (e.g., how many consults various units request), either through the electronic medical record or other sources. The data might reveal many ethics consults occurred because the institution lacks a policy on patients without decision-makers. “Hospital leaders might choose to address the issue by developing a policy, or by working with other hospitals and organizations to orchestrate legislative change,” Lesandrini suggests.
Ethicists should be able to describe their work in the “language” of administrators, as Lesandrini puts it. Hospital leaders are not familiar with ethics terms such as “distributive justice” or “beneficence.” Instead, administrators talk in terms of shorter lengths of stay or preventable readmissions. “Ethics services should be asking: How does the work we do align with the values or mission of the hospital?” Lesandrini stresses. “It behooves ethicists to understand the strategic plan of the organization.”
If ethicists do this effectively, it is possible hospital leaders might invest in an additional full-time ethicist or another specific resource for the ethics program. At some hospitals, ethics work is funded specifically because one or more hospital leaders are advocates. “But that’s hit or miss — and is also very administrator-dependent,” says Philip M. Rosoff, MD, former chair of the Duke Hospital ethics committee.
Ethicists can try to identify leaders to recruit as ethics advocates. If the ethics advocate leaves, though, funding for ethics could be discontinued. Ethicists can enlist broader support by demonstrating their value to various leaders at the organization in as explicit and preferably quantifiable way as possible. “Administrators are always impressed with numbers — especially if they show a service line to be saving or making money,” Rosoff says.
That is difficult for clinical ethics, but there are some possible approaches. “One can look to financial models for the efficacy of palliative care as an example,” Rosoff suggests.
Philanthropic donations are another possibility to generate ethics funding.
“If a hefty donation comes with ‘strings attached,’ such as it will only come about if there are matching funds from the institution, then that could be persuasive,” Rosoff adds.
Ethics work aligns with many issues that are top of mind for hospital leaders. How can ethicists measure that?
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