Preventive Ethics - National Center for Ethics in Health Care - US ...

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Part III: ISSUES—A Step-by-Step Approach to Preventive Ethics Part 1II ISSUES: A Step-by-Step Approach to Preventive Ethics This section describes the ISSUES approach, a practical, systematic approach to preventive ethics. This approach involves six steps: I IDENTIFY S STUDY S SELECT U UNDERTAKE E EVALUATE S SUSTAIN an Issue Be proactive in identifying ethics issues Characterize each issue Clarify each issue by listing the improvement goal Prioritize the issues and select one the Issue Diagram the process behind the relevant practice Gather specific data about best practices Gather specific data about current practices Refine the improvement goal to reflect the ethics quality gap a Strategy Identify the major cause(s) of the ethics quality gap Brainstorm possible strategies to narrow the gap Choose one or more strategies to try a Plan Plan how to carry out the strategy Plan how to evaluate the strategy Execute the plan and Adjust Check the execution and the results Adjust as necessary Evaluate your ISSUES process and Spread Sustain the improvement Disseminate the improvement Continue monitoring 25
Part III: ISSUES—A Step-by-Step Approach to Preventive Ethics Using the ISSUES Approach Based on established principles and methods of quality improvement, the ISSUES approach was developed to help preventive ethics teams improve the systems and processes that influence ethics practices in a facility. While the facility’s quality management staff may use standard QI methods, such as “Plan-Do-Study-Act” (PDSA), to address clinical or managerial quality issues, ISSUES is designed specifically to address ethics quality issues. How are ethics quality issues different from other quality issues? In one sense, they aren’t— on some level every quality issue has an ethical or values component. But as a practical matter, ethics quality issues are distinct in that (1) they give rise to uncertainty or conflict about values, that is, to ethical concerns and (2) the organization’s existing systems and processes are inadequate for dealing with those ethical concerns. When there’s no uncertainty or conflict at all surrounding an issue or if the uncertainty or conflict relates to something other than values (e.g., the controversy is about the medical evidence or interpretations of the law), then the issue is generally not seen as an ethics issue but instead as some other type of issue, say, a clinical or legal issue. Whether an issue is defined as an ethics quality issue or another type of quality issue also depends in large part on the institutional context in which the issue arises. If a facility has an established and effective mechanism for dealing with a particular issue, then that issue may not be appropriate for a preventive ethics approach. Let’s say, for example, that quality concerns have been raised about how clinicians interact with so-called “noncompliant” patients. In a facility that has in place a well-functioning committee to help clinicians deal with such patients, the quality concern should be referred to that committee. But in a facility that doesn’t have such a committee, the quality concern might be an appropriate issue for the preventive ethics team to take on. Even if quality concerns around noncompliant patients aren’t dealt with by preventive ethics, ethics input may still be important in the deliberations of the committee that does address it. In contrast, when there’s controversy about “the right thing to do” or the “right way” to do it, that’s usually a sign of uncertainty or conflict about values, which suggests an ethics issue. For example, the practice of disclosing adverse events to patients is becoming more widely accepted, but health care professionals in this country still vary considerably in their understandings of what information should be disclosed, how, when, and by whom. Standards about disclosure of adverse events differ from one institution to the next, are rapidly evolving, and often stimulate impassioned debates about values. So issues relating to disclosure of adverse events might well be considered ethics issues. The ISSUES approach is specifically designed to address ethics quality issues, but with minor modifications it can be applied to other kinds of quality problems. By the same token, other approaches could be modified to address ethical issues. The following figure crosswalks ISSUES and FOCUS-PDSA, a common quality improvement approach. Although the steps are presented in a linear fashion, it’s important to realize that ISSUES is a fluid process and the distinction between steps may blur in the context of a specific ethics issue. At times, steps may have to be repeated to achieve a particular improvement goal. 26
Page 1 and 2: Improving Ethics Quality in Health
Page 3 and 4: Authors Ellen Fox, MD Director Nati
Page 5 and 6: Executive Summary Executive Summary
Page 7 and 8: Part I: Introduction to IntegratedE
Page 19 and 20: Part II: Introduction to Preventive
Page 29: The Preventive Ethics Coordinator w
Page 33 and 34: Part III: ISSUES—A Step-by-Step A
Page 61 and 62: References References 1. Jha AK, Pe
Page 63 and 64: References 44. Walshe K, Shortell S
Page 65 and 66: IntegratedEthics Glossary is good o
Page 67: For more information about the Inte

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