41 Innovative strategies to improve effectiveness in clinical ethics
A large tertiary healthcare organization has a full-time clinical ethicist who is responsible for ethics consultation, education, policy development, and research. A recent accreditation survey identified a number of gaps in clinical ethics services across the organization. The clinical ethicist is already over-extended and is at risk of burning out. The Vice-President responsible for overseeing the ethics portfolio wonders what can be done to enhance support for the clinical ethicist, strengthen ethics capacity across the organization, and improve the overall effectiveness of clinical ethics services.
What is clinical ethics effectiveness?
The ultimate goal of any clinical ethics delivery model is improved patient care. As more healthcare resources are invested in clinical ethics services, questions are increasingly raised about whether these services are effective in improving the quality of patient care and whether they justify investments of limited healthcare resources. In this chapter, we identify some key challenges to existing clinical ethics delivery models and suggest four innovative strategies to improve effectiveness in clinical ethics services in healthcare organizations.
Since 1995, when James Tulsky and Ellen Fox convened the Conference on Evaluation of Case Consultation in Clinical Ethics (AHCPR, 1995), there has been a marked increase in scholarly attention to the study and evaluation of clinical ethics, particularly related to the ethics consultation component of clinical ethics (e.g., McClung et al., 1996; Orr et al., 1996; Schneiderman et al., 2000). This has been described as a new phase in the clinical ethics movement (Aulisio, 1999). As the field of clinical ethics continues to develop, it will not be sufficient for clinical ethicists “merely to mean well”; they must also be able to demonstrate effectiveness (Aulisio, 1999). While the goals of clinical ethics are generally clear – namely, the identification, analysis, and resolution of ethical concerns arising in the delivery of patient care (Siegler and Singer, 1988) – it remains unclear how clinical ethics effectiveness should be defined and evaluated.
Defining and evaluating clinical ethics effectiveness is complex for several reasons: (i) the different perspectives of multiple stakeholders on effectiveness (e.g., healthcare managers, patients, clinicians, society), (ii) the different levels at which evaluation can take place (i.e., individual ethicist, clinical ethics service, organization), and (iii) the diverse activities within the clinical ethics portfolio that must be evaluated (i.e., consultation, education policy development and research) (Griener and Storch, 1992; Aulisio et al., 2000). To date, most evaluative efforts have focused on identifying core competencies for clinical ethics practice (ASBH, 1998) and benchmarks of clinical ethics effectiveness from the perspective of those who deliver the services (Godkin et al., 2005). The perspectives of other stakeholders, such as patients, family members, and healthcare managers, have not been adequately explored (Cleary and Edgman-Levitan, 1997). For healthcare organizations, the most relevant concern is whether clinical ethics services are effective in improving local delivery of patient care. Consequently, the unique patient populations served by an organization, existing clinical ethics capacity within the organization, and the mission and values of the organization would be key considerations in evaluating the effectiveness of clinical ethics service in improving patient care. So while it is important that there be a continued emphasis on identifying evidence-based practices in clinical ethics and developing general benchmarks of clinical ethics effectiveness to use across clinical ethics programs, some component of evaluating clinical ethics effectiveness will necessarily be context dependent.
Why is clinical ethics effectiveness important?
Ethics is increasingly recognized as an important component of high-quality clinical care (Woolf, 1994; Cleary and Edgman-Levitan, 1997; Wynia, 1999, 2006; CCHSA, 2004; JCAHO, 2007). Indeed some commentators, such as Wynia (2006), have suggested that ethics “just might be the realm of quality that many patients care about most of all.” Demonstrating clinical ethics effectiveness is important in healthcare institutions for the purposes of assessing quality and identifying areas for improvement, increasing efficiency and impact, justifying allocation of resources, influencing policy, and disseminating knowledge (Silva, 1998; Wynia, 2006). Additionally, in Canada and the USA, accreditation standards now require healthcare organizations to have formal mechanisms in place to help staff to deal with ethical issues related to client care and business practices (CCHSA, 2004) and to demonstrate “ethical behavior in care, treatment, and services and business practices” (JCAHO, 2007).
The dominant model for clinical ethics service delivery in healthcare institutions has been the lone ethics consultant model – also referred to in the literature as the “lone ranger” (Fox et al., 1998) or “beeper ethicist” model (McGee, 1995) – operating with or without the support of an ethics committee. The role of the clinical ethicist (or ethics committee) generally includes ethics consultation (including research ethics), policy development, education, and research (Storch and Griener, 1992; McNeill, 2001; Slowther et al., 2001). The lone ethics consultant model faces three challenges: integration, sustainability, and accountability (Silva, 1998; Berchelmann and Blechner, 2002; MacRae et al., 2005). When accountability for clinical ethics is delegated to the clinical ethicist alone, it is difficult to achieve integration of ethics across the organization and to meet demand for clinical ethics support in a sustainable way. Accessibility of clinical ethics services among patients and family members is often particularly limited within this model.
How should I approach clinical ethics effectiveness in practice?
In this section, we describe four innovative strategies to improve the effectiveness of clinical ethics services in healthcare organizations. These practical strategies were developed and piloted by the University of Toronto Joint Centre for Bioethics (JCB) in response to the challenges identified above: integration, sustainability, and accountability. The JCB is a partnership network among the University of Toronto and 15 health organizations (13 academic and/or community hospitals, one community care access center, and one science organization), each of which has at least one full-time clinical ethicist. The strategies include (i) the “hub and spokes” model for clinical ethics service delivery, (ii) leadership and management skills training for clinical ethicists, (iii) ethics strategic planning, and (iv) evaluation of clinical ethics services.
Strategy 1: the “hub and spokes” model for clinical ethics service delivery
The hub and spokes model is an innovative model of clinical ethics delivery. In contrast to the traditional lone ethics consultant model, the hub and spokes model envisages an integrated institution-wide ethics network comprising the clinical ethicist (“hub”), who provides core ethics leadership, and ethics resource leaders with training in ethics (“spokes,” e.g., clinical staff), who help to build local ethics awareness, knowledge, and skills in clinical settings across the organization (Figure 41.1).
One of the strengths of this model is its adaptability to different organizational contexts, as well as its flexibility in operational design. For example, within the JCB partnership network, the spokes at one acute care hospital are physicians in three core clinical areas (critical care, oncology, family medicine), a portion of whose salary is paid by the organization for the purpose of providing local ethics support. By contrast, one rehabilitation hospital has professional practice staff (e.g., social workers, physiotherapists) as spokes, whose local ethics roles are written into their job descriptions as protected time. Some organizations within the JCB network augment the model with a “clinical ethics forum,” made up of the hub and spokes, a senior management representative, and other key stakeholders (e.g., patient/family representatives, board members, quality and risk managers, chaplains). In addition to providing an important community of support for the hub and spokes, the forum is a mechanism for developing strategies to improve and monitor clinical ethics effectiveness and for reinforcing ethics accountability in the organization (MacRae et al., 2005).
The hub and spokes model contributes to improved clinical ethics effectiveness in three ways. Firstly, it improves ethics integration. By positioning spokes locally, ethics support is more readily accessible to staff, patients, and family members and can be more immediately incorporated into patient care decision making. Secondly, it improves sustainability. The integrated structure offers a more sustainable clinical ethics service because it does not depend exclusively on the efforts of any single individual, thereby lessening the risk of isolation and burnout characteristic of the lone clinical ethicist model. Finally, it improves accountability. Although it has generally been recognized that healthcare institutions are accountable for ethics in clinical care, this model takes an important step toward formalizing this accountability and recognizing clinical ethics “not just as the clinical ethicist’s role, but as an integrated part of everyone’s role” (MacRae et al., 2005).
The hub and spokes model can also be implemented across organizations. For example, the JCB’s Clinical Ethics Group, which is made up of all of the clinical ethicists and clinical ethics fellows who work in JCB partner organizations along with members of the JCB’s leadership team, meets on a weekly basis for case review, professional development, and collaboration on creating and testing innovative clinical ethics practices. The group places significant emphasis on peer support and quality assurance, which group members describe as an invaluable component of their local clinical ethics effectiveness (Chidwick et al., 2004).
Strategy 2: leadership and management skills training for clinical ethicists
Leadership can be defined as “the process through which an individual attempts to intentionally influence another individual or a group in order to accomplish a goal” (Pointer and Sanchez, 2005). The hub and spokes model involves a significant shift in the clinical ethicist’s role. As the hub, the clinical ethicist’s responsibilities include providing core leadership to the integrated ethics network, mentoring and coordinating the spokes, strategic planning, and evaluating and monitoring clinical ethics effectiveness (MacRae et al., 2005). In some institutions, it may also involve budgeting, managing staff, and reporting to senior management or the board of directors. As healthcare organizations face budget constraints, many clinical ethicists face the challenge of justifying the “value-for-money” of their activities. Sustainability may depend in part on the clinical ethicist’s ability to influence the decision-making process, whether through a senior management champion or their own persuasiveness. Senior managers in JCB partner organizations are increasingly calling for clinical ethicists to play a greater ethics leadership role, including participation in broader organizational initiatives that have significant ethical implications for patient care (e.g., pandemic influenza planning, resource allocation). Consequently, clinical ethics effectiveness requires a certain amount of institutional intelligence (i.e., practical knowledge about how the organization works functionally and politically), as well as leadership skills.
Clinical ethics training does not typically involve professional development in leadership or management skills. What leadership training clinical ethicists do receive tends to be informal (i.e., learning from experience) or a combination of formal mentorship by a senior manager, executive coaching, or continuing education seminars in management for clinicians. To our knowledge, there is no leadership program developed with clinical ethicists in mind. To fill this gap, the JCB developed and piloted a six-month leadership program for its affiliated clinical ethicists and clinical ethics fellows in 2005/2006. With the academic support of faculty from a local management school, the program was designed to link the classroom experience with the practical realities of ethical leadership in healthcare organizations. Classroom learning focused on three key themes: effective leadership, change management, and interpersonal skills related to networking and dealing with interpersonal conflict. Over the course of the program, each clinical ethicist conducted a leadership project in their organization under the preceptorship of his/her senior manager and with the peer advice of two or three other clinical ethicists. On the last day of the program, each clinical ethicist had the opportunity to present his or her leadership project and to receive constructive feedback from a panel of senior managers from JCB partner organizations.
Strategy 3: ethics strategic planning
The demand for ethics service is often so great and so varied that ethicists feel they must be all things to all people, which is an unsustainable objective. The JCB has developed an ethics strategic-planning process and has piloted it across eight partner organizations. The objectives of the ethics strategic-planning process are (i) to develop a vision for the clinical ethics portfolio aligned to the organization’s strategic directions (mission/vision/values), (ii) to reach agreement on focused priorities related to the vision, and (iii) to develop an action plan that includes clear mechanisms and indicators of effectiveness. The strategic planning process is conducted in three steps.
A key strength of the ethics strategic planning process is its broad engagement of institutional stakeholders. This strengthens the integration of clinical ethics by aligning clinical ethics services with stakeholders’ needs, building a sense of shared responsibility for ethics across the organization, and creating a network of support for the hub and spokes. Moreover, by linking the clinical ethics service to the organization’s mission, vision, and values, the ethics strategic plan advances the organization’s strategic directions. Finally, it provides an explicit accountability framework for monitoring, improving, and evaluating organizational performance in relation to clinical ethics and, ultimately, for justifying a sustainable resource base.
Strategy 4: evaluation of clinical ethics services
All clinical ethics services should have explicit performance standards and a formal evaluation strategy to monitor progress, facilitate ongoing quality improvement, ensure alignment with current organizational needs and goals, and hence, enhance accountability for the organizational resources invested in the service. Clinical ethics services can be evaluated against a number of benchmarks and quality indicators, including strategic plan priorities, locally developed indicators (e.g., action plan), and/or accreditation standards. This suggests the need for a multimodal evaluation strategy, including both qualitative and quantitative data related to short- and long-term goals of the clinical ethics service as well as to the overall goal of improving patient care.
To address some gaps in knowledge around clinical ethics effectiveness, the JCB initiated the Project Examining Effectiveness in Clinical Ethics (PEECE). The study objectives were three-fold: (i) to examine the services, structures, and activities of nine clinical ethics services in JCB partner hospitals (see Godkin et al. [2005] for a detailed review of findings related to this objective); (ii) to identify specific policies, processes, and practices stakeholders defined as effective; and (iii) to investigate stakeholders’ views on clinical ethics effectiveness. To address objectives two and three, individual interviews and focus groups were conducted with a broad range of stakeholders including senior managers, clinical ethicists, ethics committee members, clinicians, patients, and family members. Stakeholders defined clinical ethics effectiveness primarily in terms of process indicators related to quality issues (e.g., patient-centered care, communication, inclusiveness) rather than more clinically oriented indicators such as number of hospital admissions or length of stay (Tracy et al., 2005). In addition, they saw clinical ethics effectiveness as a bedside-to-boardroom phenomenon, which should be evaluated at both the clinical and the organizational level and should include patients’ and family members’ views. A number of potential quantitative and qualitative evaluation strategies were suggested by stakeholders including, for example, global assessments of organizational culture, performance measurement tools (e.g., patient/staff satisfaction surveys, staff and board performance evaluations), and formal debriefings with affected stakeholders following clinical ethics interventions (e.g., consultation, education sessions). Based on the PEECE data and our experience with JCB partner organizations, Table 41.1 identifies key parameters, for which specific local indicators could be derived, to evaluate clinical ethics effectiveness in practice.
A key lesson learned in the clinical ethics services of JCB-affiliated institutions is the importance of incorporating a formal evaluation strategy into daily clinical ethics practice. This type of daily management of clinical ethics effectiveness can be likened to a sailor embarking on a sea journey with a clear destination in mind, a map to guide the way, and the necessary skills to steer the ship – but who must adjust course according to the wind and the sea conditions in order to reach the destination successfully. Experience shows that clinical ethics services are more likely to be effective if the clinical ethicist has clear goals linked to the needs, values, and goals of the organization, gathers real-time information and feedback from key stakeholders related to these goals, and uses this information to make mid-course corrections in clinical ethics services.
The case
The Vice-President and the clinical ethicist should consider taking the following steps. Firstly, they should explore developing a broader network of ethics support throughout the organization (e.g., the hub and spokes model). Secondly, depending on the previous experience of the clinical ethicist, it may be advisable to augment the clinical ethicist’s expertise with leadership and management skill training. Thirdly, an ethics strategic-planning process should be conducted to create an institution-wide vision for clinical ethics and ensure that the clinical ethics service’s priorities are aligned with the organization’s mission/vision/values and ethics needs, and to build on the organization’s existing ethics capacity. Finally, an evaluation strategy should be developed to monitor, improve, and evaluate the performance of the clinical ethics service in relation to its action plan and other indicators of clinical ethics effectiveness. Following these steps will help to ensure that the organization’s clinical ethics service is integrated, sustainable, accountable, and ultimately more effective.