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Before evaluating its performance, measure ethics committee's standing
Does your institution understand and support its ethics committee?
Before an ethics committee takes the time and effort to evaluate its performance, the members might want to step back and examine its standing within the institution. How well integrated is it? Does it have support at all levels of administration? Even in large institutions, ethics teams might be surprised by how they are regarded.
Take, for instance, a major university-affiliated medical center where a large department developed and put into effect an end-of-life care policy completely without the knowledge of or input from the ethics committee.
"That says to me, 'Stop ... Think ... Why?'" says Ann Mills, Msc, MBA, co-director of the Program for Ethics and Policy in Health Care at the University of Virginia Center for Biomedical Ethics and Humanities. "The head of the ethics committee should have gone to the department head and asked, 'Why were we not asked for input? Are we not communicating effectively?'"
Mills, co-author of two books on health care organization ethics and an assistant professor of medical education at the University of Virginia, says an annual "how are we doing" evaluation is really the second part of revealing the effectiveness of an ethics committee. The first step is to find out the ethics committee's place in its institution, both from the committee's perspective and from the viewpoint of the rest of the institution.
A committee on paper only?
"You have to determine if your ethics committee has support at all levels of your institution's administration, and to have that they have to understand why the ethics committee is there, what it does, and how it is of significant benefit to the organization. Otherwise, it's there on paper only, just so that when The Joint Commission comes in, they can say, 'Yes, we have an ethics committee,'" says Edward M. Spencer, MD, director of developing health care ethics programs at the University of Virginia.
Ethics committees began springing up as fixtures in U.S. hospitals in the 1970s following the high-profile Quinlan and Cruzan end-of-life cases and stepped-up requirements by the federal government over institutions that conducted research involving patients or research subjects. In the early 1990s, the Joint Commission on Accreditation of Healthcare Organizations (now The Joint Commission) issued a standard requiring accredited hospitals to establish a "mechanism" by which ethical issues in patient care and professional education would be handled.
This vague standard was defined as a requirement to establish ethics committees, but created no guidelines for satisfying what an ethics "mechanism" should do.
"When ethics committees got started, they were created as a basic care entity and were there to protect the rights of patients and educate all levels of their institutions to the rights of patients," Spencer explains. "But now, patient rights are understood by every level of an institution, so the job of an ethics committee is no longer just that. What they have to do now is consider policy issues, and support from higher levels of the institution in asking them to do these things is extremely important."
In its 2001 report on institutional ethics committees, the American Academy of Pediatrics (AAP) Committee on Ethics noted the increased scope of ethics committees at some institutions.
"Recent trends in the financing and provision of health care have raised concerns about the impact of institutional commitments such as managed-care contracts, integrated systems, and performance incentives on the care of patients," the AAP committee wrote. "[Institutional ethics committees] are being looked to in some institutions as a venue within which these concerns might be addressed."1
Some ethics committees left out
Determining how your ethics committee is viewed by the institution is fairly easily determined, Mills says.
"If an ethics committee doesn't have a budget, it can ask itself why," she says. "If the reason is because the administration doesn't take the ethics committee seriously, then that's the real question that needs to be addressed."
Likewise, the committee can look at who it reports to — if it's a low-level hospital official that might be an indication of the importance the administration accords the ethics committee.
"Look around and look at who the senior, well-respected members of the organization are. Are any of them on the ethics committee?" Mills adds. "If you haven't been able to attract to the committee the senior and well-respected members of the organization, you have to ask why you haven't."
Spencer says ethics committees are no longer strictly patient care bodies, and shouldn't consider themselves as such. Ethics committee members should reflect the institution as a whole.
"Get someone from administration, someone from nursing administration — not just a nurse manager," he suggests. "Anyone with an interest in ethics, no matter where they might be in the organization."
While he says he is not prone to advocate for the use of consultants, Spencer says a consultant with experience in the organization of ethics committees can be extremely valuable in determining what role an ethics committee has in an organization, and what role it could have.
"These preliminary issues have to be addressed first," Mills adds. "If those things are not in place, and if the ethics committee is not able to get them in place, I don't see how anyone will be interested in having an ethics committee developing policy."
Do administrators know what you do?
Traditionally, one of the duties of an ethics committee has been to educate the institution's employees on ethical issues. But Spencer says committees shouldn't neglect educating their hospitals on what the committee does, and its value to the organization.
"Ask senior administration officers how well they understand what the ethics committee does. Often, they don't understand at all," he says.
Spencer insists that ongoing education programs that involve all levels of the institution, from the board of directors down, are critical for both familiarizing the institution with the ethics committee and instilling the idea that the committee has an important role to play outside of patient care.
"Set up a one- to two-page checklist of things that an ethics committee should be involved in, and ask yourselves whether or not these things are being done, and if they aren't why they aren't being done," he says. "You may say, 'For our institution, maybe we don't need that aspect, but we should understand and pay attention to it, because maybe we would want to consider it for the future, or not.'"
That initial evaluation of what the ethics committee is doing and what it should be doing "will tell you a lot, and from there you establish the benchmarks for success," says Mills.
From there, the ethics committee and administration will be able to clearly see whether ethics have been treated as separate from the administration of the health care organization — a division Mills says is "a myth."
"If the hospital is determining what kinds of large capital expenditures to do this year, shouldn't it also focus and be informed on the mission and values of the organization?" she asks.
Turnover can be good
Ethics committees should experience some degree of turnover, Spencer says, to include the insights of people who are interested in ethics and willing to contribute.
"Some committees do better with little turnover, but I think there needs to be some," he explains. "The ones that are more structured tend to be in bigger, more academic institutions, and there may need to be some specific turnover rate."
On the other hand, he says some committees may find that a specific turnover time or rate may not be the best practice.
"If someone is involved in doing some important work and they are turned over, you might never get that work back, so you have to have some flexibility when you're talking about turnover," he says.
Turnover should never involve an automatic rotation, where names are drawn arbitrarily for placement on an ethics committee.
"There has to be a biding interest in ethics, because it's a committee that does a lot of work," he cautions. "They have to be willing to do the work and to get a lot of education on their own, because sometimes there aren't enough resources for them to get the education they need as new members of an ethics committee."
Mills says those who study organizational ethics have recognized a growing difficulty in recruiting physicians to ethics committees, a trend that she says is disturbing.
"Because of the pressure that physicians are under now, they just don't have time to breathe. But without physicians on your ethics committee, you have a lack of credibility," she points out. "So I do think it behooves an ethics committee to think about the future generation of ethicists, and in making calculations about turnover to think about recruitment."
Mills says once an ethics committee and its institution know what the committee's role is and how best it can serve as many levels of the organization as possible, then a process of evaluating performance and effectiveness can be created.
"Often the people we teach [at the Center for Biomedical Ethics] are concerned with how to evaluate themselves and their committees, without standing back to see what the committee is really trying to do or not do," she points out. "Ethics programs need to be a part of the culture of a health care organization, not an isolated [entity]."
For evaluations to be meaningful, Spencer adds, "it's important for ethics committee members to buy into this idea that it's necessary for them to evaluate themselves, and to understand where they fit into the administration and into medical activities, and to formally decide they need to have an evaluation every year, two years, three years."
Evaluations should include some of the same questions time after time, so data and results can be compared from year to year, Spencer says.
"This process has to be more than just going to a meeting. It's having a half-day or several workshops to see where we are and where we're going."
1. American Academy of Pediatrics, Committee on Bioethics. Institutional ethics committees. Pediatrics 2001;107;205-209.