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

Part III: ISSUES—A Step-by-Step Approach to Preventive Ethics
Step 3: Select a Strategy
With a clear understanding of the ethics quality gap, the team should next work to identify
the probable causes of the gap, brainstorm potential improvement strategies to narrow it,
and focus in on a particular strategy.
S SELECT
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
Identify the major cause(s) of the ethics quality gap
Many methods can be used to identify causes of the gap between current practices and
best practices. One of the more common is root cause analysis, which is often applied to
patient safety incidents. VA policy defines root cause analysis as “a process for identifying
the basic or contributing causal factors that underlie variations in performance.”[52] A
root cause is “one of multiple factors (events, conditions or organizational factors) that
contributed to or created the proximate cause and subsequent undesired outcome and, if
eliminated or modified, would have prevented the undesired outcome.”[53] Typically, multiple
causes contribute to the gap between current practices and best practices.
Root cause analysis:
• focuses primarily on systems and processes rather than individual performance
• investigates the underlying systems through a series of “why” questions
• continues until all aspects of the process are reviewed and all contributing factors
are considered
• identifies changes that could be made in systems and processes through either
redesign or development of new processes or systems that would improve
performance[46]
Just as mapping the process behind a practice (in Step 2) requires collecting information
directly from people who are involved, identifying the major causes of an ethics quality gap
also requires input from people who know and/or use the process. Secondhand conjecture
about other people’s motives isn’t reliable. For example, program staff may believe that
elderly patients don’t use automated telephone help systems because “they’d rather talk to
someone face to face,” when the real reason is that these patients have slow reaction times
and can’t push buttons in the time allowed.
A cause-and-effect (or “fishbone”) diagram can also be a useful tool to graphically represent
potential causes for why there is a gap and help to focus the team on what causes might be
most amenable to change. Figure 5 shows an example of a fishbone diagram illustrating
the causes behind one facility’s failure to identify potential surrogates during the hospital
admissions process:
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