Unlike clinical areas, ethics services have no consistent way to measure their work. The lack of quantifiable data makes it hard for hospital leadership to comprehend. “Hospital administrators live in the world of productivity measures. They don’t fully understand what the world of clinical ethics is doing,” says Joseph Sayegh, MBA, administrator of the Baylor College of Medicine Center for Medical Ethics and Health Policy in Houston.
A group of ethicists at Baylor wanted to quantify the work of clinical ethics consultants. “Our goal was to try and standardize how we define and report consultation activities at different hospitals, to better understand what our consultants do, communicate what we do to our stakeholders, and use data to identify trends in the services,” Sayegh says.
The first step was to define an ethics consult; there is no standardized definition. To some, it means a formal process where all stakeholders are interviewed in multiple meetings. To others, it includes informal discussions, such as an ethicist moving into the hallway to answer a question.
In networking with peers at ethics conferences, Sayegh hears a wide range of opinions on how to define an ethics consult. Baylor’s ethicists identified five core activities that constitute an ethics consult: The initiation portion (which includes information-gathering to find out what is going on), the interaction portion (which includes clinicians meeting with family and/or the patient), a closeout (which includes making recommendations), follow-up to learn whether the recommendations were followed, and documenting in the patient’s chart.
At first, the group quantified the work of ethics consults using time, looking at how long it took consultants to complete these five activities. “But we found that basing it on time penalizes experts in the field,” Sayegh reports.
A highly efficient ethicist with many years’ experience completes these tasks faster than a trainee. This made it appear the more experienced consultants spent less time (and performed less work), which was misleading.
Instead, the group decided to try a new approach — to quantify ethics work using relative value units (RVUs). Using RVUs, if a fellow takes 30 minutes to gather information from the family but a faculty member takes half that time, the work is quantified in the same way. “We use a process called an RVU crosswalk to identify corresponding CPT codes that can be tied to the activity the consultant is doing to develop a framework to assign an RVU value,” Sayegh explains.
Family medicine or clinics can control how many RVUs they generate based on how many patients they see. This makes it possible to link reimbursement to RVUs. In contrast, clinical ethics cannot anticipate volume.
“I look at clinical ethics much more like an emergency physician. There is zero control over who comes through the door and what encounters you have,” Sayegh observes.
This makes using RVUs to determine reimbursement a tricky proposition in the ethics field. “We don’t have any control over what comes through the pipeline,” Sayegh says. “If it’s a quiet night in the ER, it’s not like we are not going to compensate providers.”
Also, RVUs reflect only part of the ethics consultant’s work; it only includes what the consultant is doing within the clinical ethics consult service. RVUs do not include important, valued activities like institutional grand rounds, policy development and review, or education. “Those other pieces aren’t really accounted for. This is just a slice of the pie,” Sayegh says.
In fact, if ethicists are doing a really good job with education, consult volume might decrease. “People can deal with simple, straightforward ethical questions that come up,” Sayegh says. The ethics service has gathered some preliminary data on the RVU model. “We did a three-month pilot to validate the model, and currently we have about nine months of data collected in our current iteration of the database. The next big challenge is how we can benchmark against that,” Sayegh says.
If necessary, the data can be presented to hospital leaders to justify the ethics service. “It can ensure staffing is correct and help identify potential burnout. It helps our fellows in their training, and gives them data they can take to the job market,” Sayegh adds.
Ethicists studied a few other clinical service lines that, like the ethics service, are low-volume but high-contact. One example is genetic counseling. “They don’t have a lot of volume. But with the volume that they do have, there’s a lot of contact with the patient,” Sayegh says.
The ethics service has not presented the data to hospital administrators. There are no immediate plans to use the data to request additional funding. For now, the RVUs are simply a way to measure the work of ethics consultants. Standardizing the definition of ethics consults would allow different institutions to compare their ethics services. RVUs could help determine if additional ethicists are needed. It also could show how ethics consults affect closely tracked hospital metrics, such as length of stay.
“Others have tried to do that and have not been able to really nail it down. That is a super-complicated problem,” Sayegh laments.
Regardless, the RVU model has opened the door to more effective communication with hospital administrators. “Right now, it’s hard to make the case that you need more money for the ethics program if you present it in an abstract way and not in the same ‘language’ as hospital leadership uses,” Sayegh says.
For ethics, there is tremendous value in talking in terms administrators understand. “When we meet with hospital leadership, I have gotten the question ‘How does this translate to RVUs?’ several times,” Sayegh adds.
Unlike clinical areas, ethics services have no consistent way to measure their work. The lack of quantifiable data makes it hard for leadership to comprehend. Administrators live in the world of productivity measures. They do not fully understand the world of clinical ethics. A group at Baylor is working on the a solution that, if nothing else, would help everybody start to speak the same language.
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