The past 10 years have brought to the forefront a need to rethink how healthcare organizations approach the development of an ethical culture and how this impacts the organization’s response to conflicts or uncertainties about values. Historically, this work has been split among compliance and several other departments. In the early 1990s, organizations moved toward the development of ethics committees. Most acute care and some skilled nursing facilities and hospices accepted this model of developing an ethics committee to serve three core functions: ethics education, ethics policy review and development, and ethics consultation. This approach, however, has several drawbacks.
The primary challenge with an ethics committee model guided by the tripart functions is that it does not consider the way ethics integrates into the fabric of the organization. Given the growing complexity of the healthcare field, it’s a good time for leaders to transition away from the narrow model of ethics committees to a broader notion of ethics programs, which focus more on building and establishing an ethical culture. The following are key components to a robust ethics program, inspired by models proposed by The Catholic Health Association and The Veterans Health Administration.
Ethics Consultation
A robust ethics program includes a service staffed by appropriately trained individuals who are available and responsive to the needs of patients, families and staff and provided in a timely manner. The consultation service addresses clinical, organizational and research ethics cases in both a proactive and retroactive manner, and focuses on continuous quality improvement of the service.
Ethics Expertise
Given the complexity of work within an ethics program, it is recommended that institutions seriously consider the quality of training for program personnel. A good start is to seek out individuals who possess the Healthcare Ethics Consultation Certification, or HEC-C, that the American Society of Bioethics and Humanities offers. This certification establishes that the individual has the foundational knowledge in ethics to work with patients, families and providers to resolve conflicts or uncertainties about values. Ideally, those who lead a robust ethics program will have further certification or levels of education such as a terminal degree in a relevant field.
Ethical Research/Quality Review
A robust ethics program not only conducts research on ethics-related topics but also is involved with its organization’s institutional review board, where applicable. In addition, strong ethics programs typically reflect a culture of continuous quality improvement. For example, it is recommended that an ethics program undergo an annual assessment of the ethics education offered through the program to determine if it is meeting the needs of the institution and all stakeholders.
Ethical Leadership
In a robust ethics program, there are two aspects of ethical leadership that need attention. First, it is essential that the C-suite and other top leaders support the program and raise awareness across the organization. Second, resources are made available for leaders’ ethical development. These include self-assessments, conflict resolution assistance, an ethical decision-making framework for the organization and access to an ethics expert or service that can assist them in resolving ethical challenges.
Ethics Education
Like a committee model, an ethics program structure provides ethics education to a wide array of constituents within the organization. One role of this educational arm is to develop staff members’ moral awareness, which can increase their ability to address the ethical challenges they may face. A robust ethics education program also includes a regular needs assessment, implementation and evaluation. The program also considers how ethics education could be incorporated into staff members’ daily work and integrated into areas such as new employee orientation, nursing residencies or fellowships and graduate medical education.
Ethics Policy Development and Review
Under a program model, policies and procedures are regularly reviewed to ensure consistency between the policy and the organization’s mission, vision and values. Historically, the scope of policy work normally considered has often been limited to clinical functions (e.g., informed consent, DNR orders, brain death), as the work of ethics committees was relegated to the clinical space. Within an ethics program approach, however, the scope of review is broader. If the program’s goal is to enhance and improve the organization’s ethical culture, the ethics program will need to be involved in reviewing policies across the organization, from finance (e.g., charity care) to human resources (e.g., wages and benefits) to many other areas.
Ethics Integration/Prevention
Part of a robust ethics program’s goal is to ensure ethical decision-making processes are woven into the organization’s cultural fabric. Examples include engaging IT stakeholders to add ethical decision-making components to evaluation of new technologies and encouraging the integration of ethics into clinical rounds on intensive care units. Furthermore, ethics programs should implement proactive measures and processes to reduce and prevent various ethical challenges from recurring. For example, a regular review of data from the ethics consultation service may reveal that a large proportion of ethics cases focus on identifying the correct authorized decision-maker for a patient. In working to prevent these cases from arising, the ethics program could provide education on the floor or develop additional tools to assist care providers.
Ethics Outreach
A robust ethics program actively connects and engages with the community. Examples of outreach include working with local universities to provide education and partnering with them to bring new voices into the field of ethics, and working with local judicial systems to train future guardians on decision-making standards for wards of the state. In doing so, the ethics program can focus upstream and tackle issues that affect their community and potentially the organization.
Ethics Strategy/Oversight
An effective ethics program includes a mechanism for developing a robust organizational strategy that integrates with the overall strategic plan. This mechanism can provide feedback to the program as it progresses on its strategic plan and objectives, making recommendations where necessary. Some organizations have used an ethics committee in this role, whereas others have transitioned to different structures such as system advisory groups. The program model clearly differentiates itself from the ethics committee model because it focuses on long-term plans for the program.
Ethical Culture/Climate Assessments
One key differentiator between the ethics committee model and the ethics program model is the focus on developing a robust ethical climate within the organization. As part of that development, a robust ethics program would include within its scope and role the implementation of an ethical culture assessment. Those in robust ethics programs can use this data to improve system and unit-based culture. For example, in using the data from an ethical culture survey, ethics program resources could develop action planning sessions with leaders about how they can improve their immediate culture.
Time to Transition
Developing these services can result in significant benefits to employees, patients and the organization itself. Moving toward a program-based model will require commitment from organizational leadership, and resources and public support. The benefits, however, far outweigh the costs. The time has come for organizations to re-evaluate their ethics functions and change to a program model.
Jason Lesandrini, FACHE, is assistant vice president, ethics, advanced care planning and spiritual health, Wellstar Health System, Marietta, Ga., and founder and principal of The Ethics Architect (jlesandr@gmail.com).