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02/21/2013

Evaluating Ethics Quality: The Time Has Come

Ellen Fox, M.D.

The idea of evaluating ethics quality in health care is not new—but until now, it has proven to be easier said than done. The latest issue of AJOB Primary Research aims to jumpstart progress on ethics quality evaluation. It features six Open Access articles from the VA’s National Center for Ethics in Health Care that describe our real-world experience evaluating ethics quality as part of IntegratedEthicsTM (IE)—our comprehensive model for managing ethics in health care organizations. Ethics quality is the foundation on which IE is built. IE’s concept of ethics quality is broad, encompassing practices from the bedside to the boardroom, and described here.

The potential significance of the new issue is summed up in this blush-inducing quote from the lead article, a thoughtful commentary by Bette-Jane Crigger, Director of Ethics Policy for the American Medical Association, and Matthew Wynia, Director of the AMA’s Institute for Ethics:

The remarkable and helpful body of work described in this special issue will be, we believe, influential well beyond the VA system.

The second article in the series describes the development of the IntegratedEthics Staff Survey (IESS), an assessment tool that provides a broad snapshot of staff perceptions of ethical practices. It also gives examples of how IESS results have been used in the VA health care system. Articles three, four, and five describe those results in detail, focusing respectively on clinical ethics, research ethics, and organizational ethics. The sixth article describes the development and use of the IntegratedEthics Facility Workbook (IEFW), which helps health care organizations evaluate their local ethics programs relative to specific quality standards established for the IE model. The paper provides four years of data demonstrating significant improvements relating to ethics quality.

In the final article, I reflect back on what we have learned so far, and propose a five-point agenda for future work. A key point is inter-institutional collaboration, which will create tremendous opportunities to standardize data collection, compare data within and across institutions, answer research questions, establish benchmarks, track progress over time, and accelerate improvement.

Here’s how this article describes my vision for the future:

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. Ethics quality evaluation and improvement will be fully integrated into the organizational mainstream… [Ethics quality will be seen as] something that can be legitimately managed, measured, and systematically improved.

Admittedly, much more work is needed to make this vision a reality. But a major obstacle has been overcome: there are now validated instruments to work with (from our group and others, most notably the Ethical Force Program). The IE assessment tools, including the IESS and the IEFW, are available on the IntegratedEthics website free of charge. We also have early evidence that evaluation can spur action that can lead to ethics quality improvement. Equally exciting, we may be on the brink of being able to demonstrate associations between ethics quality and other important organizational outcomes such as patient satisfaction, employee morale, lawsuits, and even clinical outcomes.

The next few years will be critical. The Affordable Care Act calls for the development of a national quality improvement strategy and the establishment of national quality measures for health care. As health care policy makers and organizations begin to implement these provisions, this creates a unique opportunity for us in the field of bioethics. To take advantage of it, we need to come together as a community, not just to ensure that ethics quality measures are included in this effort, but to refine the concept of ethics quality and how it is evaluated.

We need to agree on a set of meaningful and valid metrics that are practical for use on a broad scale. We need to create a consortium of collaborators, engage in joint projects, use common measures, standardize data collection methods, establish benchmarks, and track progress over time.  We need to share our best practices, data, and collective wisdom to galvanize progress in the field.

In short, we need to find ways to work synergistically toward a common goal of evaluating and improving ethics quality in health care.

The time to make ethics quality an integral part of healthcare quality management has finally come.

Disclaimer:  The views expressed are my own and not the views of the U.S. Government or the Department of Veterans Affairs.

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