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Revised consultation guidelines offer models for improving quality
Revision could serve as springboard to better EC processes
Hospital ethics boards now can refer to national guidelines when developing procedural standards and processes for evaluating quality of ethics consultations (EC) and institutional EC processes.
The revised "Core Competencies for Health Care Ethics Consultation," scheduled at press time to be published by early April 2011, contain these and other new sections relating to health care ethics consultations. The original core competencies guidelines, introduced in 1998, and the 2011 revised version are published by the American Society for Bioethics and Humanities (ASBH) in Glenview, IL. (For ordering information, see resources, below.)
"These guidelines are one of the most effective and cited documents ever published in the field of ethics consultation in the world," says Andrea Frolic, PhD, a clinical and organizational ethicist at Hamilton Health Science of McMaster University Medical Center in Hamilton, Ontario, Canada. Frolic is on the core competencies task force for the second edition of the guidelines.
Frolic has used the revised core competencies guidelines as they were evolving to recruit and train a team of health professionals who desired specific expertise in ethics consultation. "I also used that document for a performance evaluation of their skills, knowledge, and attributes as consultants," Frolic says. "I've found it a guiding light throughout the recruitment period and training process."
The hope of members of the core competencies task force is that the guidelines will serve as a go-to resource for people who are doing ethics consultations in hospitals, says Anita J. Tarzian, PhD, RN, associate professor, family & community health, University of Maryland School of Nursing, and program coordinator for the Maryland Health Care Ethics Committee Network, Law & Health Care Program, University of Maryland School of Law, all in Baltimore, MD. Tarzian chairs the core competencies task force for the second edition. "We are looking at strategies for getting the guidelines into the hands of people on ethics committees and who are doing ethics consultations," she says. "When it first came out in 1998, it was seen as a core resource for people on ethics committees. At that time, there was a focus on voluntary standards and a fear that you would usurp the health care providers doing this as part of their job. Since then, we've learned you can't have a handle on medical ethics if you don't include the clinical piece."
Healthcare decision-making and ethics consultations have reached a level of complexity that calls for standardization and a way to assess and ensure quality and competency, Tarzian notes. "It's time to take ethics consultation to another level, focusing on the standards of the service as opposed to the competency of the individual consultant," she says.
The revised guidelines carry this philosophy forward with a new focus on procedures and measuring or evaluating quality and effectiveness, Tarzian says. The guidelines hold institutions accountable for having some process for measuring the quality of their ethics consultant service, Frolic says. "A lot of academic medical centers already do this," she adds. "For those folks who have a more informally structured service, this will challenge them to really enhance their program. It's a radical concept, and I'm excited about that."
While some ethicists might take issue with the idea of measuring quality and efficiency in this realm, there are some practical reasons why it's necessary, Tarzian notes. Ethics consultants are responsive to timelines, for example. "To take a month to ponder whether or not it's OK to allow a family to keep a brain-dead pregnant woman alive on a ventilator so they could keep the baby is not helpful," Tarzian says. "Also, if you have 30 people involved in formal ethics committee meetings, and you don't need 30 people, then you are taking up their time and should figure out how to provide a quality service that makes good use of your institution's resources."
One model for assessing quality that is cited in the revised guidelines is the Department of Veterans Affairs' Integrated Ethics model from the National Center for Ethics in Health Care. It's a comprehensive approach that is implemented throughout the VA health care system's 153 hospitals, says Ellen Fox, MD, chief ethics in health care officer with the Department of Veterans Affairs (VA) in Washington, DC. Fox is on the core competencies update task force. "Much has been written about the need for ethics consultation services to establish clear standards and metrics, but there has not been a great deal of progress," Fox says. "So in our system we were really responding to that need."
The guidelines task force looked for models, approaches, standards, and tools to reference and use in the revised document. Repeatedly, they returned to the VA's integrated ethics approach, Fox notes.
"The guidelines are very closely related to the integrated ethics model, and the tools are heavily referenced," she adds.
The VA also has a web-based program called ECWeb, short for ethics consultation web, that enables an ethics consultant to document consults and generate notes that can be catalogued electronically and, often, placed in the patient's record.
"It improves ethics consultation practices by tracking, trending, and documenting the critical steps taken throughout the documentation process," Fox says.
Revision addresses organizational ethics
Members of hospital ethics committees could expand their role if they embraced organizational ethics, which is another area highlighted in the revised guidelines, says Mary V. Rorty, PhD, MA, an adjunct clinical associate professor in the Center for Biomedical Ethics at Stanford (CA) University. Rorty also is on the guidelines task force.
Clinical, organizational, and ethical ethics all are part of a broader and more inclusive term called health care ethics, according to the guidelines.
"There are broader ethical concerns that don't have to do with didactic bedside clinical consultation but have to do with the ethical issues associated with quality in hospitals and concern for the ethical climate in their institutions," Rorty says.
The task force deliberately chose not to distinguish between subspecialties such as clinical ethics, organizational ethics, and professional ethics, opting instead to use the broader and more inclusive term health care ethics, the guidelines state. The guidelines gave examples of overlaps in ethics subspecialties, including these two:
The revised guidelines also are notable for what has remained the same in the 13 years since they first were published, Frolic says. "Most of the tables on knowledge and skills were only changed very minimally," she says. "That speaks to the staying power of the work that was done in the 1990s. They got a lot right in basic skills and competencies."
Learn the key items in new guidelines
Focus is on quality, measurement
The revised "Core Competencies for Health Care Ethics Consultation," by the American Society for Bioethics and Humanities (ASBH) contains new sections and tables addressing procedural standards and quality assessment.
"The report looks at what is the minimum infrastructure of an ethics consultation," says Anita J. Tarzian, PhD, RN, associate professor, family & community health, University of Maryland School of Nursing, and program coordinator for the Maryland Health Care Ethics Committee Network, Law & Health Care Program, University of Maryland School of Law, all in Baltimore, MD. "The initial core competencies report focused on what individual ethics consultants need. This revised document recognizes there needs to be an infrastructure and institutional support."
Hospitals need a policy that defines who can request ethics consultations, how these are handled, and how to evaluate them, Tarzian says.
Here are some of the new features of the core competencies guidelines:
Establish a framework for clinical and organizational ethics consultation.
Andrea Frolic, PhD, a clinical and organizational ethicist at Hamilton Health Science of McMaster University Medical Center in Hamilton, Ontario, Canada, says, "What I like about this new version is they include both clinical and organizational ethics consultation. The skills often are overlapping, and we see them as related rather than distinctive practices."
The revised guidelines expand the traditional scope of ethics consultants from being patient-specific to recognizing they might be consulted about business ethics issues, policy ethics issues, and other issues in the organizational realm, Frolic says.
"I like how this document addresses the broader practice and has a much more inclusive definition of the role of an ethics consultant, and it mirrors a lot of people's actual practice, which I think is helpful," she says.
Address HCEC evaluation and quality improvement practices.
The report evaluates consults in terms of ethics services, says Mary V. Rorty, PhD, MA, an adjunct clinical associate professor at Stanford (CA) University. "It's more about whether you have a machine that could do the job that the outcome of the job that's done," Rorty explains.
The guidelines include a table that divides the category of evaluating quality into three sections, related to structure, process, and outcomes. Examples of the recommendations under each of these sections are as follows:
Structure. "Identify root causes, underlying structural gaps (e.g., staff shortages, historical precedent, lack of funds for continuing education)."
Process. "Identify major root causes underlying process gaps (e.g., lack clear policy standards, resistance to change, unable to formulate ethics question, competing demands on staff time)."
Outcomes. "Identify major root causes underlying any satisfaction gap (e.g., misunderstanding of the consultation process, lack of timeliness, role confusion)."
Members of ethics committees could evaluate their programs by collecting data on the types of ethics consults referred to the committee and break these down by department, Tarzian suggests. "They could see that we're getting a lot of consult requests on when you can stop the ventilator in patients with X syndrome, so maybe we need to develop an educational intervention to help staff with this," she says. (See elements for a health care ethics consultant, below.)
Advance consults with process standards
17 elements to include
The revised "Core Competencies for Health Care Ethics Consultation," by the American Society for Bioethics and Humanities (ASBH) suggests including these elements in process standards for a health care ethics consultation (HCEC):