The Next Generation

1

• The Next Generation
• of
• Clinical Ethics
• Hardwiring Ethics Mechanisms
• that Add Demonstrable Value
• Philip Boyle, Ph.D.
• Vice President, Mission Ethics
• Catholic Health Association
• June 19, 2007

2
Experience/ History

• Grassroots movement
• Disillusionment
• Evidence of demonstrable difference in pt care?
• Operating dispute resolution forums with little
  power or training in mediation
• Quasi-legal protection of pt rights

3
Notable successes

• Self-education
• First responders
• Safe-place for unsafe ideas
• Identifiable institutional response
• Participative collaborative

4
Notable failures?

• Lack of demonstrable value/effectiveness
• Good intentions value
• Stuck on hard cases
• Doing ethics talking about ethics
• Volunteers amateurs
• Consistency in action
• Dispute resolution forums with no power or
  training in arbitration

5
How can we respond to the record?

• Improving?
• Refining?
• New slant on consultations?

6
How can we respond to the record?

• The Next Generation
• Proactive agent of system change
• Better integrated
• Upstream
• Improved Pt care
• Adds value contributes to quality

7
Next Generation Nationally

• How do ethics mechanisms improve quality?
• What outcomes should we expect from ethics
  committees?
• How would you assess the performance of existing
  ethics mechanisms?
• How do we hold them accountable ?
• How do we hardwire for systemic change?

8
Making a Difference?

• Principles for guidance
• Integrated
• Transformational
• Transparent
• Proactive
• Quality

9
What does this mean practically?

• Mission Vision
• May be articulated, often not
• Clear mission vision
• Catalyst facilitator for systemic change
• Not principle vehicle for change

10
What are practical implications?

• Hardwire
• Scope of authority
• Accountabilities
• Strategic annual goals
• Demonstrable values
• Reporting
• Evaluation
• Facilitators
• Program advances

11
What does this mean functionally?

• Ethics Resource Service (ERS)
• Facilitates Cases
• Educational Forums
• Systemic Ethics Group
• Quality Improvement Function
• Focus on system change
• Operationally minded
• Measures outcomes, hold accountable
• Executive Ethics Liaison- Mission

12
Membership

• ERS
• Facilitators
• Educators
• SEG
• Operationally-minded taskforces
• Selecting qualified members, not location
• Escape appearance of volunteers

13
Competencies

• ERS
• Core education
• Trained in conflict resolution
• HEC
• Long-range training
• Focus is operations, not philosophical discourse
• Skill-set operational accomplishment
• How to get things done
• How to bring about change
• How to facilitate org development

14
Ethics Resource Service

• 1. Provide competent informational
  decision-making support
• 2. Advise on recurring issues
• Systemic/structural solutions

15
Ethics Resource Servicewww.che.org/ethics/testing

• 1. Core knowledge
• Informed consent
• Capacity determination
• Advance directives
• Termination of treatment
• Confidentiality
• Truth telling
• ERDs / CST
• VBDM
• 2. Facilitation skills

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Ethics facilitation

• Common task WWW.ASBH.ORG
• Common risks
• Scope limitation of role
• Conflicting interests
• Challenges of the role
• Responding to unethical practice
• Evaluation accountability

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The Next Generation

• ERS
• Demonstrate knowledge
• Facilitators who know
• Essentials of mediation
• Self-awareness
• SEG
• Identifying ethical gaps
• Address problem not symptom
• Measuring so as to hold accountable

18
Total Quality ImprovementOperationally
Integrating Ethics

• Moral distress in nursingSt. Peters
• Six Sigma
• Patient Respect- St. Anthonys, St. Petersburg
• Cancer Drugs Decision Matrix St. Josephs, Tampa
• Trending

19
Problem Statement Acute Care patients in St.
Anthony's Hospital are not receiving coordination
of diverse care needs as evidenced in 53.33 of
documented patient complaints verbalized a
perception of disrespect towards them while a
patient at St. Anthonys Hospital from 2005-2007.

20
Fishbone
Education-Team
Education- Patients
Communication
Lack of Knowledge
Lack of Resources
Getting Info
Lack of Resources
No ID of Designated Care Giver
Time
Unclear Message
Staffing
Homeless
Unable to ID unknown factors
Knowledge
Time/ Interest
Problem Statement
Mentally challenged/non responsive /lang barrier
patient
Lack of insight
Compliance
Calm Patient
Giving Info
Time mgt healthcare
Patient Expectations
D/C Plan
Self Defense
Using the Values
Lack of Coordination of Care Services for Special
Needs Patients at SAH
Continuity
Special needs patients
Coordination
B. Act trng
Time
Staffing Needs
No one to designate patient orientation
Equipment Mgt
ED tech brings patient to floor
Overall patient orientation to hospital (lack of
standard process)
Continuity
How to obtain
No admit nurse
Nurse on floor resp. for entire Admission process
Knowing what is available
Focus for Nurse in ED- immediate pat. needs
Coordination
Managing Time
Willingness to help each other
Stressed out- demanding patients
Lack of Blue Print
Lack of team work
Transfer
Don't ask for help
Managing paient. expectations
Care Mgt.
Reactive
Providing reassurance to demanding/anxious/needy
patient families
No time to take classes
Support patient in pain
Procedure
Person
21
30 Day Action Plan
22
Implementation

• 1-2 years ERS
• Refocus ERS operations procedures
• Adjust expectations provide education
• 2-5 years SEG
• Create ethics processes
• 1 issue per year

23

• CHE.ORG/ETHICS
• CHE.ORG/ETHICS/TESTING/
• VHA
• http//www.ethics.va.gov/ETHICS/activities/integra
  tedethics.asp
• David Blake, Reinventing Health Care Ethics
  Committees, HEC 2000 (1)8-32