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

Part III: ISSUES—A Step-by-Step Approach to Preventive Ethics
especially data that is in any way identifiable. The team should take the same precautions
it would take to protect other types of quality improvement data.[50]
Questions that are potentially useful in understanding and diagramming the process
include:
• What are the scope and boundaries of the practice?
• What is the actual flow of the process behind the practice?
• Who is involved in each step of the process?
• Who else is directly or indirectly affected by it?
• How do the steps relate to each other?
• Does everyone generally approach the process in the same fashion, or does each
person, service, or unit do it differently?
• Do existing standards (e.g., policies or operating procedures) define how the
practice should be performed?
• Do staff members adhere to those standards?
• Are there unwritten “rules” that conflict with the formal standards?
• What really happens on a day-to-day basis?
With information from various sources in hand, the team should draw and label a process
flow diagram. A variety of different formats can be used. See Figure 4 (below) for an
example of a process flow diagram illustrating how potential surrogates are identified
during the admissions process at one VA facility.
Gather specific data about best practices
Next, it’s important for the preventive ethics team to gather information about best
practices to establish a clear picture of how the status quo needs to be changed. The
team should use a combination of published sources, expert advice, and (as needed)
ethical analysis to develop a description of best practices that will serve as a goal of the
improvement process.
The team members should begin gathering information on best practices by familiarizing
themselves with available ethics knowledge (otherwise known as “best thinking”[51])
relevant to the issue they’ve chosen to address. This could include ethics standards and
guidelines, consensus statements, scholarly publications, precedent cases, and applicable
institutional policy and law. The team should generally review journals, texts, and online
resources on ethics in health care organizations. In addition, it may be helpful to examine
codes of ethics for relevant professional groups, such as social workers, physicians,
researchers, health care executives, or accounting professionals. Team members should
also be sure they are familiar with applicable local and national VA policy. Reports from
national commissions, the Institute of Medicine, the American College of Healthcare
Executives, or other learned bodies may be useful as well. The goal is to understand and
to develop a well-grounded description of what would constitute ethics “best practice” and
to identify potential pitfalls to avoid in implementing change.
The preventive ethics team should also seek examples of practices from other settings
that could be adapted to fit local circumstances. Staff at other VA facilities who have faced
similar issues may be able to offer helpful suggestions about lessons learned. When
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