VA tries quality improvement approach to medical ethics

How often does a physician have enough time to discuss a treatment recommendation with a patient?

Would a doctor be reluctant to raise concerns if he or she believes a colleague's clinical abilities are impaired?

How often are notes or papers with identifiable patient information left in areas where other patients, relatives or staff members might view the sensitive material?

These are just a few of the questions the National Center for Ethics in Health Care at the U.S. Dept. of Veterans Affairs is using to query its staff at the VA Health Care System. The goal is to help facilities see what they are doing well in terms of ethics and point out areas where they could be doing more.

The concept is similar to the recent push to evaluate quality of care by asking about procedural issues such as how well physicians are helping patients control hypertension or whether hospitals are keeping infection rates low.

Ethics evaluations, though, are not so common, and surveys do not tie payment to how well facilities score. However, the idea of measuring ethics as a component of quality of care is gaining momentum, and leaders in the field say its time has come.

“This is about managing ethics the same way you manage health care quality,” said Ellen Fox, MD, chief ethics in health care officer for the Veterans Health Administration. “Ethics quality is an important area that can have a dramatic effect on health care, including life-and-death decisions. … An effective ethics program promotes better patient care, better patient satisfaction, better efficiency.”

The nation's largest health care system is sharing how its IntegratedEthics program sets ethics goals for its facilities and then evaluates and helps them improve across a broad range of ethical issues. The VA launched the comprehensive model for managing ethics in health care organizations in 2007 after it ran a demonstration project with 25 hospitals in 2006.

“These evaluation tools are designed to give a big-picture overview,” Dr. Fox said. “That is something that has been missing in the field.”

The National Center for Ethics in Health Care published a series of articles this year describing its massive undertaking to evaluate and manage ethics in the VA system. The January-March issue of AJOB Primary Research, a journal of the American Journal of Bioethics, featured seven papers describing the VA's experience evaluating ethics quality.

“It is very exciting to have an increase in the numbers of tools available,” said Matthew K. Wynia, MD, MPH, director of the American Medical Association Institute for Ethics. “We are entering an exciting time to evaluate quality of care.” The VA papers “will hopefully continue to push the conversation forward.”

Dr. Wynia and AMA Ethics Policy Director Bette-Jane Crigger, PhD, co-wrote one of the AJOB Primary Research articles, “Evaluating Ethics Quality.” They called the IntegratedEthics program “groundbreaking in its breadth.” They noted that the program isn't necessarily immediately transferable to other programs. But “despite some limitation,” they said it “provides a tangible example of a revolutionary way to think about and address the ethical challenges that arise in health care organizations.”

VA develops specialized tools

The articles in AJOB Primary Research highlight some tools that are part of the larger IntegratedEthics program, which includes educational resources, standardized approaches to various aspects of ethics work, outreach materials, and administrative tools to help organize and document work.

Several of the articles examine results from the IntegratedEthics Staff Survey, an instrument designed to elicit staff perceptions about ethical practices in their health care organization. One paper examines the IntegratedEthics Facility Workbook, designed to help health care facilities evaluate and improve their ethics programs.

The tools are “global assessment tools designed to assess overall ethics quality across a health care organization for improvement purposes,” Dr. Fox wrote in AJOB Primary Research. “When used in combination, these two … global assessment tools provide a broad snapshot of ethics quality in a health care organization.”

For example, a physician directly involved in patient care was asked to answer:

• Six questions about shared decision-making with patients.
• Six questions about professionalism in patient care.
• Four questions about patient privacy and confidentiality.
• Two questions about the experience with the facility's ethics consultation service.

In addition, six questions about end-of-life care were asked of those who worked with dying patients.

Setting ethics standards and gathering the staff's perceptions on how those standards are met has allowed VA facilities to design targeted interventions to improve ethics quality, Dr. Fox said. For example, some medical centers discovered that if a patient was dying, there was a tendency for physicians and nurses not to visit the patient as frequently. Those facilities were able to address the issue in a systematic fashion and achieve meaningful results, she added.

The approach has worked well at South Texas Veterans Health Care System, said Cheryl Padgett, RN, quality management continuous readiness coordinator for the facility. The South Texas medical center has surveyed its staff members several times and sees improvement in areas it targeted after the facility initially did not score as high as leaders would have liked.

“In theory and concept, ethics seems like a more difficult thing to measure … but they have come up with a good tool,” Padgett said. “It gives us objective feedback … [and] it has allowed us to have consistency in its approach and allowed us to drill into the areas where there is room for improvement.”

Padgett said South Texas discovered areas where it was doing well: More than 90% of surveyed staff said they would report misconduct and disclose harm to a patient. More than 90% of managers would intervene if they saw abusive behavior.

The survey also revealed areas where facilities have been able to work with staff to make improvements — for example, informing patients about the risks and benefits of a treatment and working with them to decide whether to go forward with a treatment plan.

“We are moving away from paternalistic and more focused on what patients want to happen,” Padgett said.

The VA has made the surveys and information available online. While the tools were developed for the VA Health System, Dr. Fox said they are adaptable to other organizations.

“As the largest system and a system funded by the taxpayers, we see it as our responsibility to share our tools and resources so they can be used outside our system,” Dr. Fox said.

Other efforts to measure ethics

In addition to the VA's broad-based IntegratedEthics program, other programs are under way to measure more specific aspects of an ethical climate at a facility. For example, the Communication Climate Assessment Toolkit, commonly known as C-CAT, is available to evaluate patient-centered communication. About 30 organizations are using the tool from the Ethical Force Program at the AMA. The National Quality Forum endorsed measures that are part of the program.

Leaders in medical ethics say measuring ethics in health care settings is important, even if the questions and answers aren't as concrete as measuring something such as how many patients receive colonoscopies at proper times.

Measuring ethics can show quality in the big picture, Dr. Wynia said. Although it is great to evaluate mammography and know that a hospital does well, that doesn't necessarily tell a man with Crohn's disease how that hospital may serve him, he said.

“But if you look at the ethical culture of an organization, that is something that can translate to how the organization handles many different diseases,” Dr. Wynia said. “It is useful for a much broader audience.”

For facilities with a limited budget, a broad-based survey instead of one that focuses on something such as hand washing allows them to find areas they didn't do well in and dig deeper, or to build on strengths that the survey may reveal, Dr. Wynia said.

Ethics leaders said evaluation tools are in their infancy. “Much more work is needed to demonstrate that ethics quality is something that can be legitimately managed, measured and systematically improved,” Dr. Fox wrote in AJOB Primary Research.

She said the VA plans to further evaluate and improve ethics programs and specific ethical practices. For example, she said one area of work would be finding ways to improve discussions about life-sustaining treatments to ensure that patients' wishes are known and followed.

The VA also plans to examine the relationships among various aspects of ethics quality, examine the relationships of ethics quality and other important organizational outcomes, and foster cross-institutional collaborations to evaluate and improve ethics quality.

Dr. Fox hopes the tools and the review of what the VA has done will be a resource and provide inspiration to scholars who want to develop and implement new methods for evaluating ethics quality.

“My vision is that one day, health care leaders and staff will routinely manage ethics quality in the same ways they manage service quality and technical quality in health care,” Dr. Fox wrote. “Ethics quality evaluation and improvement will be fully integrated into the organizational mainstream.”