Kaiser Permanente adopts new ethics approach, hiring staff ethicists
Initiative is designed to improve organizational ethics
One health care provider is using its approach to ethics to combat what one ethics leader in the organization calls "a perfect storm" of intense regulatory scrutiny, increased litigation, a large population of chronically ill patients in hospitals for long periods of time, and public mistrust of the health care system.
Kaiser Permanente, of Oakland, CA, having embraced the linkage it believes exists in health care between quality and ethics, has adopted an integrative ethics approach and is in the process of hiring staff ethicists, initially only in its Southern California region, which consists of about 12 service areas.
"The context is there's a lot of regulatory scrutiny. There's a lot of patients'rights standards," Paula Goodman-Crews, MSW, LCSW, medical bioethics director for KP in San Diego and co-chair of the Southern California regional ethics committee, tells Medical Ethics Advisor. "There's a setting for a lot of mistrust, and I'm not talking specific to Kaiser, but there's patient mistrust, and a lot of this was exacerbated — and maybe with good reason — about five years ago when the Institute of Medicine put out a report about medical errors."
In that report, the Washington, DC-based IOM indicated that medical errors result in about 100,000 deaths in the United States annually, sending a chill among the health care community, as well as to patients/consumers, many of whom have their own stories to tell from their own experiences in this regard.
And, Goodman-Crews notes, for those of us who may be wondering what this environment of mistrust has to do with ethics, "Well, it has to do with everything, because you have to look at the context."
The health care setting, she suggests, is one that is "really ripe for conflict."
"Sometimes, this is really, I think, the basis of what the VA is talking about [by suggesting an integrated ethics approach] — that there are a lot of organizational systems, which, although they're intended to create benefit, in fact, they're inadvertently creating ethics quality gaps," she says.
Traditionally, ethics committees at hospitals have been made up of volunteers who may or may not have specific training in medical ethics. There also has been a tendency to focus only on cases at the bedside, often after conflict already has erupted with either a patient or a patient's family.
That traditional model is now being questioned by some in the medical ethics community as outdated for the pressures faced by all parties in the current health care environment.
Rather than an ad hoc, or case-by-case, basis, Goodman-Crews suggests an integrated approach to ethics at institutions. Bodies such as the VA's National Center for Ethics in Healthcare are also advocating this new approach, whereby clinical ethicists with specific training or degrees in ethics are on staff and therefore integrated into the institutional decision-making processes of hospitals and health care systems.
"There are recurring cases at the bedside," she says. "After awhile, you start to recognize that even though you can resolve these issues at the bedside, the roots of the problems may not lie necessarily only with a communication problem, or merely a values conflict. There may be systems or processes in the organization that need to be addressed."
And that leads to the concept of addressing "organizational ethics" through an integrated staff ethicist approach, she says.
For example, after reviewing the circumstances of one bedside case, it may be possible to determine that, say, a consult was necessitated by the way "rounding" — or physicians'rounds — was conducted.
As mentioned earlier, increasingly there are large number of the elderly who are chronically ill with more than one disease or disorder, and they may be hospitalized for very long periods. Unfortunately, Goodman-Crews notes, "the way hospitals are structured, there's going to be a different specialist attached to every different part of your body."
"I think what happens, and what contributes to a sense of helplessness on the part of patients and family members . . . is that there's a lot of helplessness, because continuity of care sometimes is not great," she says. "There's different doctors. Care is not really centralized."
That, she says, is an example of an organization's processes and procedures actually contributing to a problem for patients.
"So, part of an integrative ethics approach would be I, as an ethicist . . . would discuss the case, but also perhaps create a quality improvement project designed to eliminate some of the systems gaps that are contributing to the problem at the bedside," she says.
Business case linked quality, ethics
This new approach to ethics within Kaiser, which has the greatest number of its centers in California, divided between a Northern California region and a Southern California region, began with a business presentation.
Goodman-Crews, along with her co-chair, as well as with a group of business advisers, presented their business case for an integrated ethics approach for the whole of Kaiser at that time to Kaiser's quality leadership.
According to Goodman-Crews, this group of Kaiser's leaders in quality "completely understood and embraced the link between quality improvement and ethics."
She notes that Kaiser Permanente hopes to have added three staff clinical ethicists by the end of 2009. They are currently interviewing for the positions, and she said the institution has fielded candidates from a variety of disciplines from physicians to nurses to those devoted to spiritual care.
"So, if you ask, 'Why are we doing this," it's because we believe we're going to be much more effective in being able to promote ethical practice," Goodman-Crews says.
Sources
For more information, contact:
- Paula Goodman-Crews, MSW, LCSW, Medical Bioethics Director, Kaiser Permanente, San Diego.
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