Operationalizing Justice: From Clinical to Organizational Ethics

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Organizational Ethics Workshop for Hospital Ethics Committee

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Operationalizing Justice: From Clinical to Organizational Ethics

  1. 1. SFGH Ethics Committee December 23, 2013 Kate Michi Ettinger, JD Operationalizing Justice: From Clinical to Organizational Ethics
  2. 2. Operationalizing Justice: From Clinical to Organizational Ethics  No financial conflicts of interest Disclaimers Trained in law, but not practicing attorney; nothing presented is intended as legal advice. Operationalizing Justice: From Clinical to Organizational Ethics Disclosures
  3. 3. Operationalizing Justice: From Clinical to Organizational Ethics Baseline Raise a hand if in the last 6months you have participated in one clinical situation, in which you felt the care provided to a patient was not optimal. And, raise the other hand if that sub-optimal situation was due to an institutional issue at the systems level (resource constraints, staffing, cross department issues, cross institutional issues, costs)- i.e. beyond the clinicians involved. Stand up if it has happened more than once in the last 6 months. Stay standing if it has happened in the last month.
  4. 4. Operationalizing Justice: From Clinical to Organizational Ethics Brainstorm What are organizational issues that you have encountered that seem ethically problematic?
  5. 5. Operationalizing Justice: From Clinical to Organizational Ethics Examples • decision to close a service (e.g. asthma program) due to budget concerns that service closure impacts access to care • weighing decision about innovative program to improve care delivery versus budget concerns • how to allocate scare resources (ICU) and expensive resources (dialysis) • addressing interservice transfers and the costs associated with prolonged hospitalizations
  6. 6. Operationalizing Justice: From Clinical to Organizational Ethics Examples • the “uninvited” consultant • disclosure of medical errors • management of patients with disruptive behavior • donation after cardiac death • medical futility
  7. 7. Operationalizing Justice: From Clinical to Organizational Ethics Goals How do organizational ethics and clinical ethics differ? What models have other institutions used to address organizational ethical issues? How might we approach an organizational ethics issue at our hospital?
  8. 8. Operationalizing Justice: From Clinical to Organizational Ethics How are organizational ethics and clinical ethics different?
  9. 9. Operationalizing Justice: From Clinical to Organizational Ethics Guides how clinicians use their professional power and governs the imbalance in power Clinician/Team - Pt Relationship
  10. 10. Operationalizing Justice: From Clinical to Organizational Ethics Clinical Ethics Example Mrs. K is a 82 year old nursing home resident with dementia, renal disease, and limited functional ability. Within the last month, Mrs. K has been admitted 4 times for altered mental status. Each time, after hydration and care for 1-2 days, she regains alert status and is discharged. A full work up has reveals nothing acute. These episodes appear to be caused by difficulty swallowing and dehydration. On this 4th hospitalization, the Ethics Committee is consulted.
  11. 11. Operationalizing Justice: From Clinical to Organizational Ethics Principles for Analysis: What does patient want? Respect for persons What will promote this patient's well-being? Beneficence What can we do to avoid harming this patient? Non-maleficence Justice Clinical Ethics Consult
  12. 12. Operationalizing Justice: From Clinical to Organizational Ethics Ethical Guidelines Clinical Ethics Analysis: Justice ? A member of the team expresses this view during the consult meeting: Isn’t this patient's use of expensive resources (ED, hospitalizations) an unjust allocation of resources and ethically wrong?
  13. 13. Operationalizing Justice: From Clinical to Organizational Ethics Clinical Ethics Analysis: Justice This Pt's use of expensive resources is an unjust allocation of resources and thus, ethically inappropriate. Justice is not applied at the individual level. Making decisions about this individual’s care based upon resource allocation is not ethically appropriate.
  14. 14. Operationalizing Justice: From Clinical to Organizational Ethics So, what about justice?
  15. 15. Operationalizing Justice: From Clinical to Organizational Ethics “Treating similarly situated patients similarly” What does this mean? Justice Principle Goals Fair distribution of the benefits/ burdens of societal goods Substantive Procedural
  16. 16. Operationalizing Justice: From Clinical to Organizational Ethics “Treating similarly situated patients similarly” Whose view of Justice? Societal or defined population (within a dept, at this hospital, in a county) Who is “treating”? Physician/Team, Organization, Payer How do you define “similarly situated”? Disease condition v. current status; personal factors How does one assess “treating similarly”? Based upon clinical diagnosis or other factors Access may inform whether pts are treated similarly
  17. 17. Operationalizing Justice: From Clinical to Organizational Ethics Operationalizing Justice Key Considerations Systematic approach Consistent, Fair Principled distribution of burdens/benefits Transparency Explicit consideration of competing interests Well-reasoned justification for decisions Participatory processes Inclusive of relevant, diverse stakeholders Transparent
  18. 18. Operationalizing Justice: From Clinical to Organizational Ethics Historical Care Paradigm Hospital as Silent Partner in Care Delivery
  19. 19. Operationalizing Justice: From Clinical to Organizational Ethics Hospital as Active Player in the Care Paradigm Organization to Patients Relationship
  20. 20. Operationalizing Justice: From Clinical to Organizational Ethics Hospital as Active Player in the Care Paradigm Hospital is actor on care team impacting Clinician-Patient Relationship Organization to Providers Relationship
  21. 21. Operationalizing Justice: From Clinical to Organizational Ethics Hospital as Active Player in the Care Paradigm Organization to Patients Relationship Clinical Team - Pt Relationship Organization to Providers Relationship
  22. 22. Operationalizing Justice: From Clinical to Organizational Ethics Ethical Landscape Clinical Ethics Applies to MD/Team Governs relationship Clinician-Patient Principles Respect for persons Beneficence Non-maleficence Organizational Ethics Applies to: Organization action Clinician action Governs relationship: Organization to MD/Team Organization to Patients Principles Clinical ethics ? Virtue ethics ? Business ethics? Public health ethics? Other values?
  23. 23. Operationalizing Justice: From Clinical to Organizational Ethics Three Approaches
  24. 24. Operationalizing Justice: From Clinical to Organizational Ethics System Approach VA: Integrated Ethics Program Systems-focused model to promote and improve ethical practices in health care Goal: Ethics quality “practices throughout the organization are consistent with widely accepted ethical standards, norms or expectations for a health care organization and its staff ” Targets: Ethics quality gaps Framework: Levels of ethics quality
  25. 25. Operationalizing Justice: From Clinical to Organizational Ethics Systemic Approach (VA) Decisions & Actions
  26. 26. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Systemic Approach (VA)
  27. 27. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Environment & Culture Systemic Approach (VA)
  28. 28. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Environment & Culture Ethics Consultation Systemic Approach (VA)
  29. 29. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Environment & Culture  Ethics Consultation Preventative Ethics Systemic Approach (VA)
  30. 30. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Environment & Culture Ethics Consultation Preventative Ethics Ethical Leadership Systemic Approach (VA)
  31. 31. Operationalizing Justice: From Clinical to Organizational Ethics Ethics Consultation Decisions & actions CASES approach  Clarify the request  Assemble info  Synthesize info  Explain synthesis  Support consult Systemic Approach (VA)
  32. 32. Operationalizing Justice: From Clinical to Organizational Ethics Ethics Consultation Decisions & actions Preventative Ethics Systems & Processes CASES approach ISSUES approach Identify Issue Study Issue Select Strategy Undertake Plan Evaluate & Adjust Sustain & Spread Systemic Approach (VA)
  33. 33. Operationalizing Justice: From Clinical to Organizational Ethics Ethics Consultation Decisions & actions Preventative Ethics Systems & Processes Ethical Leadership Environment & Culture CASES approach ISSUES approach Leadership Compass Demonstrate Ethics as Priority Communicate Expectations Practice Ethical Decision Making Support Local IE Program Systemic Approach (VA)
  34. 34. Operationalizing Justice: From Clinical to Organizational Ethics What does ethics have in common with chocolate?
  35. 35. Operationalizing Justice: From Clinical to Organizational Ethics Leadership Compass Ethics Consultation Decisions & actions Preventative Ethics Systems & Processes Ethical Leadership Environment & Culture CASES ISSUES VA: Integrated Ethics Program
  36. 36. Operationalizing Justice: From Clinical to Organizational Ethics System Approach (VA) Features Integrated care delivery system Multiple facilities Mandated model implemented locally Integrated Ethics Systems-focused model Ethics quality Process-driven Values-based decision making
  37. 37. Operationalizing Justice: From Clinical to Organizational Ethics Institutional Approach Montefiore Organizational Ethics  Goals:  To reconcile tensions for decisions with competing business and clinical interests  To ground and guide the approach for business decisions that had clinical implications
  38. 38. Operationalizing Justice: From Clinical to Organizational Ethics Institutional Approach Decision Making Model: • Identify the problem • Identify the key players • Diagnose the situation • Analyze the options • Ethical implications of the options • Resolution of the problem • Implementation
  39. 39. Operationalizing Justice: From Clinical to Organizational Ethics Institutional Approach Montefiore Organizational Ethics Principles I. Principle of Protecting Professional Integrity Health care organizations have a moral obligation to protect the integrity of clinical decision making and the physician-patient relationship, irrespective of the means by which the organization and their physicians are compensated or share risk.
  40. 40. Operationalizing Justice: From Clinical to Organizational Ethics Institutional Approach II. Principle of Ethics Audit Health care organizations have a moral obligation to conduct an “ethics impact audit” of all decisions affecting the allocation of health care services to particular patient populations, including the opportunity costs of those decisions. These decisions should be defensible as a reasonable way of meeting stewardship obligations, and the reasons for these decisions should be publicly accessible to the appropriate parties
  41. 41. Operationalizing Justice: From Clinical to Organizational Ethics Institutional Approach Issues addressed:  Allocating critical care resources  Justice and access to unreimbursed therapies  Guidelines for transferring patients between services  Decision making protocol for the patient alone  Confidentiality and privacy in the era of IT  Physician autonomy and the uninvited consultant
  42. 42. Operationalizing Justice: From Clinical to Organizational Ethics Institutional Approach Montefiore Organizational Ethics Features Charitable Hospital Mixed Payer System Administratively supported-driven model OE Program Subcommittee of the Ethics Committee Process: Decision Making Model (Stakeholder Approach) Principles: Protecting Professional Integrity/ Ethics Audit
  43. 43. Operationalizing Justice: From Clinical to Organizational Ethics Harvard-Pilgrim Organizational Ethics Features NP Health Insurance Company Administratively driven model OE Program To promote increased organizational skill at identifying ethical dimensions of policy/operations/budget decisions Ethics Advisory Group (diverse stakeholders) Consultative/decision support Process: Customer presents problem: Case Study & Analysis EAG reviews & discusses: publish report Principles: Provide care with compassion, treat employees with respect, act in a public spirit, spend resources reasonably Institutional Approach
  44. 44. Operationalizing Justice: From Clinical to Organizational Ethics Pittsburgh VA (2006) Features Federal hospital (regional facility) Public accountability Administratively initiated, employee led Organizational Ethics Issue: MRSA Principle: Avoidable death is impermissible (do no harm) Current metrics permit avoidable death Public Health PD Innovators: Jerry & Monique Sternin and Jon Lloyd, MD Method/Process: Positive Deviance Institutional/Issue Approach
  45. 45. Operationalizing Justice: From Clinical to Organizational Ethics Pittsburgh VA (2006) Positive Deviance Invitation & Implementation Define the problem Determine common practices Discover the positive deviants Design activities to expand PD solution Examples of Change Cross functional services Techs Janitors Chaplains Seemingly Intractable Environments: Nursing Home Institutional/Issue Approach
  46. 46. Operationalizing Justice: From Clinical to Organizational Ethics Issue Approach Contra Costa County Features Safety net hospital Public accountability Ethics committee driven Organizational Ethics: Subgroup of the ethics committee Process: Study group: Radical Respect, Commitment to Learning, Justice Principles: Virtue ethics: integrity, respect, compassion, humility, empathy
  47. 47. Operationalizing Justice: From Clinical to Organizational Ethics Issue Approach  Contra Costa County Issues addressed:  Disclosure of medical errors & adverse events  Medical futility  Determination of cardiac death  Decisions for the patient alone  Management of disruptive pt
  48. 48. Operationalizing Justice: From Clinical to Organizational Ethics Organizational Ethics Approaches System-wide  Multi-facility, addresses systems actions at all levels  Process driven  Values based decision making Institutional  Hospital, addresses organization actions  Principle driven - Stakeholder included decision making model  Organizational ethical principles Issue Approach • Ethics committee driven, addresses specific actions • Issue focused study group • Virtue ethics principles
  49. 49. Operationalizing Justice: From Clinical to Organizational Ethics Facilitators of Success  Galvanizing issues that elicit organizational concern  Facilitator with ethics and organizational skills  Including key stakeholders in deliberations  Radical respect with a commitment to learning  Passionate leadership
  50. 50. Operationalizing Justice: From Clinical to Organizational Ethics Operationalizing Justice Key Considerations Systematic approach Consistency Fair Principled distribution of burdens/benefits Transparency Explicit consideration of competing interests Well-reasoned justification for decisions Participatory processes Inclusive of relevant, diverse stakeholders Transparent
  51. 51. Operationalizing Justice: From Clinical to Organizational Ethics 1. Understand the issue/problem 2. Talk to stakeholders 3. Identify Options: -- Brainstorm possibilities -- Explore ethical dimensions of options 4. Develop Proposal: -- Integrated solution that explains rationale -- Review proposal with stakeholders for input -- Refine based on stakeholder feedback 5. Implement 6. Assess outcome/impact Suggested Framework
  52. 52. Operationalizing Justice: From Clinical to Organizational Ethics Operationalizing Justice Bibliography Beauchamp, TL and Childress, JF. Principles of Biomedical Ethics, 5th Ed. Oxford University Press, 2001. Blustein, J. Farber Post, L. Dubler, N. Ethics for Health Care Organizations. United Hospital Fund Press, 2003. Farber-Post, L. Blustein, J. Dubler, N. Handbook for Health Care Ethics Committees, Johns Hopkins University Press, 2007. National Center for Ethics in Health Care, Veterans Health Administration, Integrated Ethics: Improving Ethics Quality in Health Care. Sabin, J and Cochran, D. Confronting Trade-offs in Health Care: Harvard- Pilgrim Health Care’s Organizational Ethics Program, Health Affairs: Jul/Aug 2007. vol.26, Iss. 4: 1129-1134.
  53. 53. Operationalizing Justice: From Clinical to Organizational Ethics Thank You Stay in touch! Kate Michi Ettinger Daily Paper.li on Bioethics @k8ethics (Twitter) www.muralinstitute.org

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