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SFGH Ethics Committee
December 23, 2013
Kate Michi Ettinger, JD
Operationalizing Justice:
From Clinical to Organizational Ethics
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
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.
Operationalizing Justice: From Clinical to Organizational Ethics
Brainstorm
What are organizational issues that you have
encountered that seem ethically problematic?
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
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
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?
Operationalizing Justice: From Clinical to Organizational Ethics
How are organizational ethics and
clinical ethics different?
Operationalizing Justice: From Clinical to Organizational Ethics
Guides how clinicians use their professional
power and governs the imbalance in power
Clinician/Team
- Pt
Relationship
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.
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
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?
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.
Operationalizing Justice: From Clinical to Organizational Ethics
So, what about justice?
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
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
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
Operationalizing Justice: From Clinical to Organizational Ethics
Historical Care Paradigm
Hospital as Silent Partner in Care Delivery
Operationalizing Justice: From Clinical to Organizational Ethics
Hospital as Active Player in the Care Paradigm
Organization
to Patients
Relationship
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
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
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?
Operationalizing Justice: From Clinical to Organizational Ethics
Three Approaches
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
Operationalizing Justice: From Clinical to Organizational Ethics
Systemic Approach (VA)
Decisions & Actions
Operationalizing Justice: From Clinical to Organizational Ethics
Decisions & Actions
Systems & Processes
Systemic Approach (VA)
Operationalizing Justice: From Clinical to Organizational Ethics
Decisions & Actions
Systems & Processes
Environment & Culture
Systemic Approach (VA)
Operationalizing Justice: From Clinical to Organizational Ethics
Decisions & Actions
Systems & Processes
Environment & Culture
Ethics Consultation
Systemic Approach (VA)
Operationalizing Justice: From Clinical to Organizational Ethics
Decisions & Actions
Systems & Processes
Environment & Culture
 Ethics Consultation
Preventative Ethics
Systemic Approach (VA)
Operationalizing Justice: From Clinical to Organizational Ethics
Decisions & Actions
Systems & Processes
Environment & Culture
Ethics Consultation
Preventative Ethics
Ethical Leadership
Systemic Approach (VA)
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)
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)
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)
Operationalizing Justice: From Clinical to Organizational Ethics
What does ethics have in
common with chocolate?
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
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
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
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
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.
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
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
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
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
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
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
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
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
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
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
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
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
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.
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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Operationalizing Justice: From Clinical to Organizational Ethics

  • 1. SFGH Ethics Committee December 23, 2013 Kate Michi Ettinger, JD Operationalizing Justice: From Clinical to Organizational Ethics
  • 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. 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. Operationalizing Justice: From Clinical to Organizational Ethics Brainstorm What are organizational issues that you have encountered that seem ethically problematic?
  • 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. 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. 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. Operationalizing Justice: From Clinical to Organizational Ethics How are organizational ethics and clinical ethics different?
  • 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. 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. 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. 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. 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. Operationalizing Justice: From Clinical to Organizational Ethics So, what about justice?
  • 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. 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. 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. Operationalizing Justice: From Clinical to Organizational Ethics Historical Care Paradigm Hospital as Silent Partner in Care Delivery
  • 19. Operationalizing Justice: From Clinical to Organizational Ethics Hospital as Active Player in the Care Paradigm Organization to Patients Relationship
  • 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. 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. 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. Operationalizing Justice: From Clinical to Organizational Ethics Three Approaches
  • 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. Operationalizing Justice: From Clinical to Organizational Ethics Systemic Approach (VA) Decisions & Actions
  • 26. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Systemic Approach (VA)
  • 27. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Environment & Culture Systemic Approach (VA)
  • 28. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Environment & Culture Ethics Consultation Systemic Approach (VA)
  • 29. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Environment & Culture  Ethics Consultation Preventative Ethics Systemic Approach (VA)
  • 30. Operationalizing Justice: From Clinical to Organizational Ethics Decisions & Actions Systems & Processes Environment & Culture Ethics Consultation Preventative Ethics Ethical Leadership Systemic Approach (VA)
  • 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. 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. 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. Operationalizing Justice: From Clinical to Organizational Ethics What does ethics have in common with chocolate?
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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