EXECUTIVE SUMMARY
Stronger relationships are mutually beneficial for ethics and administrators. Ethicists can encourage hospital leaders to:
• undergo required education for participating on an ethics committee;
• shadow clinical ethicists rounding with the healthcare team;
• observe ethics consultations.
Good relations between ethics and hospital administration require a solid understanding of their distinct roles, according to Gavin Enck, PhD, system director of clinical ethics at Oklahoma City-based Integris Health.
Ethicists address underlying conflicts or uncertainties of patients’ or providers’ values. In contrast, says Enck, “Hospital administrators focus on the cost and provision of care relating not only to patients and families, but also to providers and the organization.”
There is some important, but often disregarded, common ground. Both ethics and administrators want patients to receive high-quality, respectful care. Integris Health’s CMO Tommy Ibrahim, MD, says, “Understanding these roles as having the same foundational focus reframes the relationship from adversarial to collegial.”
At Integris Health, ethicists and administrators have strengthened relationships in these ways:
• Administrators are encouraged to undergo the mandatory education for participating on an ethics committee.
• Clinical ethics invites administrators to shadow clinical ethicists rounding with a healthcare team and, when appropriate, observe an ethics consultation. This educates administrators on the role, processes, and language of clinical ethics.
“They can see firsthand how ethics connects to clinical practice and patient care,” says Ibrahim.
The ethics committee recently reviewed a consultation involving a patient’s refusal of care.
“Hospital administrators were able to see how patients, families, and providers are affected by the organization’s policy on decision-making capacity and informed consent,” says Enck. Ethicists learned how care refusals affect hospital metrics and performance outcomes.
By elucidating the effect that high-level administrative decisions have on individual people, says Ibrahim, “the ethicist helps administrators connect to the importance, and even sanctity, of their work,” says Ibrahim.
• A designated person facilitates communication between ethics and IT. When Integris created the role of clinical ethics technology liaison earlier this year, Anne Saunders initially faced skepticism both from clinicians and IT personnel. IT analysts were not convinced it would be possible to reliably capture hard data on ethics consultations due to the narrative nature of the notes. Clinicians were not sure they were comfortable with a more structured ethics consult note.
“But we have been able to rapidly develop the technological capabilities of clinical ethics while reassuring our clinician partners,” says Saunders, software analyst and instructional designer at Integris.
Ethicists did not understand how the process for developing documentation and reporting worked in the EMR. IT learned that the most relevant metrics for ethics are not easily captured.
“Ethicists learned about the capabilities, workflows, and jargon of IT,” says Saunders. Software engineers and analysts gained some insight on the technical needs of clinical ethicists in a patient care setting.
“IT became able to take an active role in ethics,” says Saunders. Together, clinical ethics and IT implemented an ethics documentation note template. This tracks 50 ethics-specific metrics for consultations on adult, pediatric, and perinatal patients.
“The skepticism around this role is gone,” says Saunders.
• Administrators invite ethicists to work groups and committee meetings.
“Traditionally, clinical ethics was only brought in when there was a problem,” says Ibrahim. Hospital leaders have found that ethics can offer a new, unexpected perspective.
“Whether in a family meeting or a board meeting, problem-solving and conflict resolution work equally well,” adds Ibrahim.
Making a Business Case
Not all ethicists are comfortable making a “business case” to administrators or speaking in terms of cost-effectiveness and resource allocation.
“There are some ethicists who dig in and say, ‘We’re in the business of value. You can’t measure value, so I’m not playing that game,’” says Steven Squires, PhD, vice president of mission and ethics at Cincinnati-based Bon Secours Mercy Health.
These ethicists object to correlating the value of ethics with outcomes important to hospital administrators, such as reduced length of stay. “But you need to speak the language of other people,” says Squires.
Quality assurance in ethics is one option. “People can see how we’ve responded and what we need to work on,” says Squires.
The health system began an annual system ethics report in 2016. This includes committee profiles, educational events and initiatives, and consultation characteristics. “These data are of interest to many, including administrators and board members,” says Squires.
The report compares the hospital’s ethics program to others of similar size and acuity. “Administrators like to know their ethics program isn’t an outlier,” says Squires. “Having an ethics committee three times the size of any other committee should, at minimum, generate questions.”
Data on the type and quantity of ethics consultations could be viewed as the proverbial canary in the coal mine. “Consult patterns can reveal larger problems,” explains Squires.
He recommends that ethics leaders multiply the number of consults in a year by the average time spent per consult, then multiply this by the average hourly wage of volunteer ethics consultants. “The resulting cost may surprise leaders who know that acute care needs a method to resolve ethics disputes,” says Squires.
Strong relationships with hospital or health system leadership are “essential for an ethics consult service to thrive,” says Margie Atkinson, DMin, BCC, director of pastoral care, ethics, and palliative care at Morton Plant Mease Hospitals/BayCare Health System in Clearwater, FL. Atkinson suggests these approaches:
• Ensure that an administrator or other high-level hospital director sits on the ethics committee.
• Develop bylaws that require the ethics committee to report at least annually to the board of directors or quality committees.
• Ensure that ethics bylaws include signatures of hospital administrators. “Administrators, including senior medical officers and chief executives, give power to the program with their ownership,” says Atkinson.
• Do not hesitate to involve administrators when faced with challenging cases that could result in high-profile media coverage. Set up a conference call “sooner rather than later,” suggests Atkinson. “Your administrators will thank you for this.”
SOURCES
• Margie Atkinson, DMin, BCC, Director of Pastoral Care, Ethics, and Palliative Care, Morton Plant Mease Hospitals/BayCare Health System, Clearwater, FL. Email: [email protected].
• Gavin Enck, PhD, System Director of Clinical Ethics, Integris Health, Oklahoma City. Phone: (405) 945-4558. Email: [email protected].
• Steven Squires, PhD, Vice President of Mission and Ethics, Bon Secours Mercy Health, Cincinnati. Email: [email protected].
Good relations between ethics and hospital administration require a solid understanding of their distinct roles.
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