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

Part III: ISSUES—A Step-by-Step Approach to Preventive Ethics
Prioritize the issues and select one
With a list of ethics issues categorized by domain and type of quality gap, descriptions of
improvement goals, and working titles in hand, the team should prioritize them and decide
which issue to address first. Because time and resources are finite, the team should select
an issue for which the improvement effort is likely to have a real impact on the facility’s
ethical practices. Questions to consider include:
• Is the ethics issue a high priority for leadership or other important stakeholders?
• Are there clear data indicating an ethics quality gap?
• How significant are the ethics issue and its effects?
• Is the ethics issue of manageable size and scope? If not, can it be broken down into
components that can be addressed individually? Can it be addressed in multiple
ISSUES cycles?
• Is it likely that the preventive ethics team will be able to bring about the needed
change?
Is the ethics issue a high priority for leadership or other important stakeholders?
Sometimes the team will move an issue to the top of the list because leaders or other
important stakeholders consider it a high priority. At other times, a priority issue may be
something that leaders or stakeholders don’t know about yet—but that the preventive ethics
team expects they would care about if they did. To prioritize effectively, the team must have
a good understanding of the mission and vision of the facility, its important stakeholders,
and its leaders and what is most important to them. In this regard, the IntegratedEthics
Program Officer may be an important resource to help the team prioritize ethics issues.
Are there clear data indicating an ethics quality gap? The team should exercise
caution in selecting an ethics issue in the absence of clear evidence that an ethics quality
gap really exists. Are current practices truly at odds with professional standards or other
important institutional values? For example, it might be suggested that some patients are
being unfairly denied access to a particular service, when in fact the service is being denied
only for legitimate eligibility related reasons. Sometimes additional information is needed to
determine whether a particular issue actually represents an ethics quality gap.
How significant are the ethics issue and its effects? To answer this question, the
preventive ethics team should consider such factors as how often the issue manifests
itself, the number and categories of people it affects, and the nature and magnitude of
those effects. Are there harmful effects on patients, employees, or the public at large? How
important is the issue in comparison to other institutional priorities?
Is the ethics issue of manageable size and scope? Critical to selecting an appropriate
issue is choosing one that the team can reasonably manage. An issue that is too large
and complex to be handled effectively with the resources available will frustrate the team
and reduce the likelihood of success. Yet even far-reaching and complex improvement
opportunities can become manageable when broken down into smaller pieces. For example,
if the ethics issue is that performance measures are creating perverse incentives with
respect to billing and coding, the preventive ethics team could effectively focus on one
problematic measure at a time, recognizing that it will likely take more than a single ISSUES
cycle to narrow the ethics quality gap.
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