A health region, with multiple hospitals and community healthcare organizations, is faced with increased pressures to improve the ethical care of patients and improve staff experience across the system. Currently the patient satisfaction scores at many of the sites are quite low and recent Health Commission inspections in some hospitals have highlighted management of consent issues and patient-centered care as areas of major concern. The staff ’s morale is waning and moral distress seems to be increasing. The CEO of the Strategic Health Authority believes that clinical ethics could potentially make a significant difference to the overall culture of the system but feels that the existing mechanisms are not that effective. She begins to consult with experts in the field to discuss how clinical ethics can help her to improve her health system.
“ABC Health Care” has an established clinical ethics program that performs a variety of functions including case consultation, education, policy work, and scholarly writing. Although ABC has received positive accreditation ratings relating to clinical ethics, many within ABC – including both administrators and clinical staff – have a general sense that ABC’s current clinical ethics program may not be fully addressing the organization’s needs. For example, the program tends to focus on a narrow range of ethical concerns, mostly related to high-profile acute situations in the intensive care and emergency units. In contrast, staff experience a much broader range of ethical issues in their work day to day, and many issues and areas go unserved. Although the clinical ethics program devotes many hours to ethics consultation, similar ethical issues continue to recur again and again. At times, ethics program staff seems more concerned about philosophical questions and principles than about the practical realities experienced by patients and healthcare staff. Overall, the clinical ethics program’s impact on everyday behavior or on organizational culture is unclear, and no measures exist to evaluate the program’s effectiveness. The CEO feels strongly that the clinical ethics program should be held accountable for its effects on the system (or lack thereof). He looks to other organizations for models of how clinical ethics programs can be used to make systems change.
According to Silverman (2000), systems thinking “is concerned with the key interrelationships, structures, and processes that control and monitor behaviour … With systems thinking, the focus is not on individuals as objects of improvement, but rather, on examining interrelationships, communications, ongoing processes, and underlying causes of behaviour with an eye towards changing interactions or redesigning the system to produce different behaviours.”
In the healthcare arena, systems thinking has been increasingly evident since the late 1980s (Berwick, 1989). Don Berwick, President of the Institute for Healthcare Improvement in the USA, has been instrumental in instilling the concept, now well recognized in healthcare, that “every system is perfectly designed to achieve the results it achieves” (Berwick, 1996). Also in the USA, the major organization that accredits healthcare organizations – the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – adopted a new set of Principles of Organization and Management Effectiveness in 1989 that strongly emphasized a systems approach to continuous quality improvement in patient care (JCAHO, 1991).
Unfortunately, clinical ethics has not caught on to this trend toward systems thinking in healthcare. To the contrary, clinical ethics has continued to focus more on the particulars than the general:more on, for example, reacting to acute situations on a case-by-case basis than on identifying and addressing the underlying systems factors that give rise to many of the ethical concerns in healthcare (Silva, 1998).
In 2001, three long-standing leaders in the field of clinical ethics wrote a paper that highlighted the history of clinical ethics, talked about key developments in the previous decade and outlined remaining challenges for the field in this decade (Singer et al., 2001). The two top significant challenges they highlighted for clinical ethics practice (consultation and committees) was the need to integrate clinical ethics work into the culture of healthcare organizations and to improve organizational accountability for clinical ethics. What these authors were pointing to is a need to understand and impact the functioning of the larger context (the system) in which the ethical issues in healthcare exist.
A systems approach to clinical ethics offers a potential for significant impact across a broad scope of healthcare. Practically speaking, a systems approach focuses on the dynamic “assemblages of interactions within an organisation or between organisations” (Emanuel, 2000). As a result, this perspective can impact the broader healthcare culture and address the “silo” problem in clinical ethics consultation (where the consultation service is perceived to operate in relative isolation from the rest of the organization) (Blake, 2000). A systems approach can improve ethics accountability by demonstrating a systemic commitment to ethics, by integrating ethics from “boardroom to bedside” (MacRae et al., 2002), and by bridging the artificial gap between organizational and clinical domains (Foglia and Pearlman, 2004).
A systems approach can help clinicians, managers, and ethics facilitators to understand and address the components of the systems that drive ethical care and behavior. These components may relate to local dynamics and practice, or they may be broader in scope to include such things as financial models, information technology systems, philosophy of care issues, rewards and incentives, historical factors, or professional boundary issues. Systems thinking may also help to decrease moral distress and disempowerment among healthcare staff – a factor that has been shown to be a major cause of staff burn-out and turnover. Moral distress has been defined as “what happens when a staff person knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton, 1984) and is something that lends itself to a deeper inquiry using systems thinking. Systems thinking applied to the problem of staff moral distress inquires into the systemic challenges that create painful ethical challenges for healthcare professionals, moving the solution beyond the staffs’ personal suffering to the possibility of changing institutional conditions that created this suffering in the first place. A similar approach can be used to move to a more patient-centered healthcare quality approach that addresses key patient and family concerns (Cleary and Edgman-Levitan, 1997).
A systems approach also helps to ensure that clinical ethics practice is collaborative with others in the healthcare organization or system. In the traditional models, clinical ethics programs and clinical ethics committees are poorly integrated across the organization and with other groups in the systems that have similar goals.
Finally, systems-based clinical ethics supports evidence-based practice and accountability to the end-users in healthcare. In this way the end-user provides the marker to the type of system that is in existence around a given situation and, therefore, lends insight into future opportunities for improvement. Such an approach requires serious study of the effects of various clinical ethics interventions on actual practice in order to drive innovation and change. This includes incorporating clinical ethics indicators into other system measurements such as patient satisfaction outcomes and accreditation scoring. The shift is one where a clinical ethics committee or consultant moves from asking questions such as, “Was this one consult or educational session successful?” to questions such as “How has clinical ethics impacted the overall healthcare culture in how it sets financial priorities, frames problems, addresses staff morale, etc?” – or even to such fundamental questions as, “Is this the system of healthcare we ought to have in order to achieve the goals we strive to achieve?”
There are no regulatory requirements for ethicists in Canada, the USA or the UK, and no formalized competency requirements or understanding of “effective” clinical ethics practice. This lack of standards in clinical ethics is strangely accompanied by drive to require clinical ethics services by oversight bodies (Canadian Counsel on Health Services Accreditation, 2004; Royal College of Physicians, 2005; JCAHO, 2007). It is only a matter of time before ethicists are going to need to define what counts as effective practice. One danger in this shift towards effective practice is that ethicists will respond to this challenge by being too inwardly focused and will spend time exclusively on their own professional issues such as their working conditions, core competencies, and codes of conduct for ethicists without, at the same time, looking outwardly for impact on the people that ethics is meant to serve. A field that is too inward looking may soon make itself irrelevant in the broader healthcare context and die under its own weight. It seems that a reasonable approach for those in ethics may, therefore, be to look beyond the characteristics of individual consultants and consultations to an examination of how clinical ethics interventions are actually affecting patients, healthcare professionals, and organizations and healthcare more broadly (Fox and Tulsky, 1996; Leeman et al., 1997). In this way systems-based clinical ethics programs can offer leadership in the field as a standard bearer to which regulating bodies may turn.
Changing organizational behavior and/or culture is no small task. As leaders of three large clinical ethics networks in three different countries, we have each been working for a number of years to find innovative ways to meet this challenge. In the USA, EF leads the National Center for Ethics in Health Care of the Veterans Health Administration, which is the largest healthcare system in the USA, with roughly 8 million enrolled patients, 200 thousand employees, and 1300 sites of care delivery. In the UK, AS leads the support program for the national network of clinical ethics committees. This programme includes a website (http://www.ethics-network.org.uk) and educational resources for all clinical ethics committees in the UK, of which there are approximately 85. In Canada, SM is the Deputy Director of the Joint Centre for Bioethics, a partnership with the University of Toronto and 15 diverse healthcare organizations in the greater Toronto area and with the largest group of in-hospital full-time clinical bioethicists in Canada and perhaps in the world.
Despite the fact that the authors work in three different countries, with three different cultures, healthcare-funding structures, and settings, we have all evolved independently towards systems thinking in our clinical ethics practice. Below we have identified our top 10 leading practices that we agree are essential when applying systems thinking to clinical ethics.
A clear organizational mandate means that clinical ethics programs must have a well-defined organizational role, clear responsibilities and expectations for that role, and the status, authority, and resources needed to carry out that role.
By engaging with the “real world,” we mean that the clinical ethics program must be well attuned to the everyday reality of the healthcare organization and the “real world” it seeks to affect. From our experience, historically two streams of activity have struggled to claim the “ownership” of the field of clinical ethics: the highly academic field of applied ethics on the one hand and the grassroots movement of clinicians, clinical programs, and hospital ethics committees on the other. This has often resulted in a split in the field of clinical ethics between scholars studying bioethics in universities, who often have extensive theoretical training but relatively little experience with day-to-day health-care conflicts and operations, and clinicians and members of clinical ethics teams in hospitals, who may have little formal ethics training but understand very well the practical realities of the modern healthcare organization and the ethical dilemmas therein. Systems thinking allows one to move beyond this ownership question to a question of impact and seeks to integrate theory and practice for the betterment of healthcare quality.
Application of a system-based clinical ethics program can benefit from creation of networks in a way that provides more impact and higher benefit and service to individuals belonging to the network than what they would be able to realize if a similar effort were made at the individual level.
A clinical ethics program should be practical and useful: that is, it should be focused on serving the practical needs of the organization of which it is part and helping to advance the organization’s mission and goals. Some clinical ethics centers and programs have a strongly academic or theoretical bent, serving primarily as “think tanks.” Some see it as their mission to enhance dialogue [http://wings.buffalo.edu/faculty/research/bioethics/ news1], encourage debate [http://www.fom.sk.med.ic.ac.uk/medicine/about/divisions/ephpc/pcsm/research/meu/], or enrich the moral imagination [http://www.ethics.emory.edu/]. In contrast, centers like ours are service oriented and focus on results. Specifically, we aim to improve actual on-the-ground ethical behavior throughout the healthcare organizations we serve.
Systems thinking allows clinical ethics to be proactive and not just reactive. In the case of current ethics consultants, the practicing lone bioethicist often struggles with isolation and overwork, and lacks appropriate integration, sustainability, and accountability to move beyond a few priorities and reactive efforts (MacRae et al., 2002). Clinical ethics needs to function strategically if it is to do any more than react to crises. Clinical ethics that is geared at systems change is not as focused on the crisis situations as it is on the overall context of these situations, which may allow for more thoughtful, systematic, well-thought-out strategic directions for ethics interventions. As clinical ethics becomes more systems focused, interventions (e.g., consultation or educational sessions) are seen as opportunities to understand the “root cause” of a problem or behavior and to suggest changes or alternative systems models that will reduce rather than create ethical difficulties for clinicians and patients. The goal is wider than resolving the immediate ethical conflict involving an individual patient and his or her clinicians. In some cases, it can be to eliminate the underlying cause of the ethical conflict completely from the system. This “upstream approach,” which looks at what causes the problems or what leads to certain behaviors, focuses not on the failures of individuals but instead on the opportunities in the system for improved outcomes. Ethicists may also choose to impact public policy, for example by choosing to collaborate with clinicians or scholars to conduct research to influence a thoughtful response to a larger trend they are noticing in the field. Or they may plan overall goals through a formal ethics strategic-planning process (Gibson et al., 2007) to help to highlight the institution’s priorities with respect to ethics.
Accountability requires that ethics committees, consultants, and programs work to an appropriate standard, have clear lines of reporting, and are situated in such a way to impact change at the level required at the institution.
Many ethics programs make the mistake of focusing exclusively on specific decisions and actions on a case-by-case basis. But to have a real and lasting impact on ethical behavior, ethics programs must target not just individual behaviors but also the underlying root cause organizational factors that influence them. In particular, individual behaviors are powerfully influenced by an organization’s systems, processes, environment, and culture (http://www.va.gov/integratedethics/primer.cfm).
If an ethics program focuses only on specific decisions and actions, without addressing broader organizational influences that may facilitate or impede ethical practices, employees are more likely to experience moral distress or a feeling that they know the right thing to do but are unable to do it (http://www.cna-nurses.ca/cna/documents/pdf/publications/Ethics_Pract_Ethical_Distress_Oct_2003_e.pdf#search=%22moral%20distress%22). In contrast, when ethics is integrated throughout an organization’s systems, processes, environment, and culture, employees recognize ethical concerns and discuss them openly. They feel empowered to behave ethically and know they will be supported when they “do the right thing.”
Both of the cases at the beginning of this chapter represent scenarios that could benefit from systems thinking. In the first case, the situation is based in a health region that spans many health-care delivery sites, while the second scenario is based in an organization. In both cases, a systems approach to clinical ethics requires an explicit recognition by clinical ethicists and other ethics facilitators of the different interrelational systems of values within and outside the organization as well as a focus on culture-wide ethical integrity.
More specifically, a systems approach to clinical ethics in these cases requires using the original functions associated with clinical ethics – consultation, education, policy development, and scholarly work – for the purpose of improving the overall culture and system of care delivery, including, but moving beyond, care of the individual patient. It means seeking an impact at all levels of the organization from “boardroom to bedside,” making ethics as available and visible at senior executive meetings for example, as it is in clinical rounds. It means working with senior leaders to effect change throughout the organization, sitting at the senior tables and clinical tables and offering useful and effective tools and resources to help them to manage the real problems they face. It requires that the ethicist understands the context of healthcare and its business model and structure in order to identify how change can occur within that particular setting, while still appreciating the considerable variation in cultures that occurs from one healthcare organization to another. It may also mean building liaisons with other departments and with professionals focused on organizational change, such as quality departments, patient relations, and risk management, while maintaining the unique viewpoint that ethics offers to the discussions that usually surface in these arenas. It means acknowledging the many different ethical codes (professional, financial, personal) and clashes that exist in the complex systems of healthcare (Thurber, 1999). It also means integrating ethics into the key “thrust” areas in the network, organization or region (such as patient safety, pandemic influenza planning) as an important contribution from ethics that may affect the overall system of care.