Several highly recognized thought leaders in healthcare are encouraging organizations to become “learning healthcare systems,” which the Agency for Healthcare Research and Quality describes as a “health system in which internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice. As a result, patients get higher quality, safer, more efficient care, and healthcare delivery organizations are better places to work.”
The National Academy of Medicine and the National Institutes of Health also are proponents of the learning healthcare systems model.
Healthcare organizations across the country have implemented this approach by being more systematic and data driven in gathering and applying both internal and external knowledge to improve the efficiency and quality of patient care they deliver. The domain of patient care has tended to be the focus of this strategy. For example, the learning healthcare systems approach uses data and evidence to improve stroke care and patient outcomes, decrease outpatient wait times, or help to prevent medical mistakes.
An area of focus that has received little attention in the development and implementation of learning healthcare systems activities is how to gather data and learn from ethical conflicts. This is an area ripe for intervention.
The concept of seeking approaches to decrease the number of ethical challenges and their inherent organizational impact on the staff, patients and the organization is not new. In 1990, Robert Arnold and colleagues published the article, “Preventive ethics and the promotion of ethical decision-making” in Clinical Respiratory. Additional articles have also been published that affirm the importance and the value of the concept of “moving ethical conflicts upstream.” A few published models for performing an ethical decision-making process have included a final step focusing on what can be done in the future to prevent the same type of conflict. Despite this important approach to ethics conflicts, few ethics programs or committees have systematically implemented this preventive approach (the exception being Veterans Health Affairs facilities).
Examples of frequently experienced ethical conflicts include:
- Patient or families demanding an intervention that physicians do not want to perform because it is outside the standard of care.
- Decision-making for minors.
- Racist patients.
- Surrogates not making decisions based on a patient’s desires.
- Administrator and clinician engagement in conflicts of interests.
In addition to being frequent, many of these kinds of ethical conflicts are recurring, impacting quality, value of care and professional standards. The presence of these repeat ethical conflicts often fosters staff moral distress that can lead to burnout, dissatisfaction and job turnover. Furthermore, repetitive ethical conflicts can negatively affect an organization’s margin. When an ethical conflict occurs, the organization incurs immediate direct costs associated with the time that the involved staff and ethics consultants spend on addressing the situation, thus decreasing staff efficiency in fulfilling other duties. Some ethical conflicts also bring about legal and risk management costs. A learning healthcare systems approach can help ethics committees and organizations address recurring ethical conflicts and their implications.
Many ethical conflicts are addressed and resolved through the development of clinical and organizational ethics committees, and using consultation services; however, the resolution of the specific conflict is only one important step. Rather than only responding to ethical conflicts through in-the-moment provision of ethics consultation services, the learning healthcare systems organization approach should be applied to the work of ethics committees by regularly using improvement methodologies to decrease the presence of ethical conflicts.
Implementing a learning healthcare systems approach means that data related to ethical conflicts is routinely collected, categorized and analyzed. The data would include the kind and location of the conflict, as well as the contextual elements contributing to the conflict. The data is continuously aggregated and analyzed. The collection of such information related to ethical conflicts can be incorporated into an improvement process to anticipate or potentially prevent the issue from actually becoming a conflict requiring an intervention.
To illustrate, ethical conflicts surrounding the issue of medical futility occur regularly in the inpatient setting. The situation transpires when a patient or family member demands a level of care or intervention that the healthcare team knows will be nonbeneficial in achieving the care management goals. The healthcare team experiences intense moral distress from the situation and seeks insight from the ethics consultation service. As a result of multiple conversations, the healthcare team, ethics consultants and the patient reach an agreed-upon sound care management approach.
Rather than the situation ending with the patient and healthcare team reaching an agreement regarding the appropriate management approach, the ethics consultants seek a meeting with the involved staff. This step is a recognition that the basic ethical conflict regarding patient demands for nonbeneficial interventions has occurred frequently in the particular clinical setting. The ethics consultants and others meet to discuss potential improvement approaches with the various involved stakeholders to explore two fundamental questions. The first question, without casting blame on anyone, is why did the ethical conflict happen? The second question is, as a healthcare delivery system, what could be done differently to diminish similar future situations from becoming an ethical conflict?
Such thoughtful reflections could lead to the creation of ethics practice guidelines and staff education regarding an ethically justified approach to such situations. The development, implementation and assessment of the prevention strategy could lead to a consistent ethically grounded approach in the area where the conflict occurred. The strategy could also be shared with other areas in the organization to cultivate a consistent approach to such recurring situations.
There are several steps that can be implemented by organizations and their leaders to ensure that ethics committees are applying the learning healthcare systems approach.
- Cultivate the collaboration among clinicians and administrators, quality improvement professionals and ethics committee members to capitalize on the synergy of organization and ethics committee aims.
- Review and expand the functions of ethics committees in light of the preventive ethics literature.
- Expand the knowledge and skills of ethics committee members to include competency in learning healthcare systems thinking and methods.
- Consider the inclusion of recurrent ethical conflicts in the organization’s learning healthcare systems priorities.
Learning healthcare systems have emerged in organizations throughout the country to enhance the quality and value of healthcare. The work of ethics committees can be used within the concept of learning healthcare systems, and it can be applied to address recurring ethical issues to decrease them, including their inherent organizational impact, and foster an ethical, aligned healthcare culture and organization. s
William A. Nelson, PhD, HFACHE, is director/professor of the Ethics and Human Values program at the Geisel School of Medicine at Dartmouth, Hanover, N.H. (william.a.nelson@dartmouth.edu). Susan A. Reeves, EdD, RN, is executive vice president, Dartmouth Hitchcock Medical Center, Lebanon, N.H. (susan.a.reeves@hitchcock.org).