Use an ethics program to improve quality
Dilemmas spur changes at Michigan agency
The ethical questions wouldn’t go away and, clearly, neither would the staff until some answers could be found.
Employees at Associated Home Care in Sandusky, MI, kept coming to Pat Black, RN, quality coordinator, asking about rules for talking on cell phones. Popular literature included stories about ethical dilemmas other home care agencies faced over such issues as cell phone confidentiality, and at every conference Black attended, someone was talking about ethics.
"Everywhere I turned, I was inundated with this," she says. "I felt we had to make some decisions before something happened that we had to be proactive, not reactive."
Ethics and quality improvement may not seem like natural partners. But according to Black, what started out as an unlikely pairing has led her agency to make changes that will have a positive effect on patient care.
"We had been getting a lot of questions that could only be labeled ethical or moral," Black recalls. "No one knew where to put them, so they came to me." Among the topics being mentioned by concerned staff members: withdrawal or withholding of treatment, confidentiality in an era of cell phones and fax machines, and when patient choice in care becomes patient noncompliance.
"There seem to be more questions now than there ever were before," she says. Last year, Black felt that the time for talking was over and the time for action had come. "We had to have guidelines for nurses; not necessarily concrete answers to these questions, but some sort of guide that would help them wade through these issues."
Black brought her concerns to the agency’s management team, which includes the director of home care, as well as clinical, quality, and office coordinators. This team formed the core of the ethics committee.
Black sent letters to other people in the community whom she wanted to be involved, such as physicians, attorneys, clergy, nurses, consumers of agency services, and people from the professional advisory committee. She also contacted her own organization’s management and quality improvement staff. In the end, 14 people accepted the invitation to join.
"We came up with some of the topics. Others came from some of our 30 nurses," Black says. The ideas were then run by the professional advisory committee, which includes people from the board of health, local hospitals, and community organizations. The committee didn’t just sign off on the original set of ethics topics, but came up with additions.
Ethics meetings held quarterly
Within four months, the ethics committee had pieced together a policy. It called for regular quarterly meetings at which ethics topics would be discussed. The topics come from any staff member who has an issue, or from the management team, which might be aware of issues facing other agencies, says Black.
In addition, special meetings can be called by the executive director if an issue arises suddenly between meetings, and it is deemed to be important enough to demand immediate attention. Thus far, no such emergency has arisen.
Black implemented the following additional measures, most of them concurrently, to complete the ethics program:
1. Develop a record-keeping system.
Each meeting’s agenda and minutes are recorded and kept in a central location for review. Also included is a list of people present at the meeting, topics discussed, and any articles or information provided to the members in the week or so prior to the meeting. The next meeting date and topic are also noted.
2. Educate management and staff.
At management meetings and staff inservices, Black talked about the code of ethics, plans for the ethics program, and how it would affect them in their job.
3. Develop a list of experts and other resources for additional information.
This is ongoing, says Black. This list currently consists of an attorney who has experience in ethical issues, people involved in ethics from other area organizations like hospitals or skilled-nursing facilities, national organizations such as the National Association for Home Care (NAHC), and libraries that can provide articles on the topic. One library she often uses is the National Library of Science in Bethesda, MD [(800) 683-8480].
4. Incorporate policies into personnel policies.
Black says this just involved putting any changed policies and procedures into the personnel manual and notifying staff of the changes. "We didn’t want to have this be just another piece of paper to the staff," Black says. "We wanted this to be relevant."
Sites communicated differently
Although the initial steps were completed, there have been some glitches. For instance, Black doesn’t think the program was well communicated to the staff. One of the two locations of Associated Health has done a great job at communicating the program, she says. "They went to the nurses’ meetings and told them about the ethics meetings," she says. "They were encouraged to attend and asked for topics and input. They got a sense that this was important."
It is a different situation at the second location. There, no one was told about the ethics program. "When I talked to them about it, I got a lot of blank stares," she admits. It is something Black is working on remedying now. "If people see where something can contribute to better client care, they are more willing to buy into it, and take part in the process. But they have to know about it first."
Despite those problems, there have been positive changes. One of the initial questions that led to the whole ethics project dealt with confidentiality in an age of electronic media that are not totally secure. The agency changed its release-of-information form for patient intake to include a section allowing lab reports to be faxed. A disclaimer reads: "Fax machines are not as confidential as the mail or as a phone call."
Using numbers, not names
There were policy changes implemented for cell phone and answering machine usage, too, says Black. Now, staff members never speak patient names when they call answering machines or cell phones. Instead, an identifying patient number is used. Verbalization of patient-specific information over cell phones or on answering machines is also banned.
Another possible change could occur for patients who refuse treatment. "We don’t have anything concrete in place yet, but we are discussing what this means, whether it is a choice issue or a compliance issue."
At the location where there is greater communication and participation, Black says any change in policy or procedure is talked about extensively, implemented, and then reviewed two months later to see whether it works.
The ethics committee now meets quarterly. The next goal is to improve communication so it involves the entire staff. Topics are increasingly being suggested by everyone from secretaries to nurses to managers.
Black hopes to meet the following longer-term goals:
• to evaluate the system annually (something that will come up later this year);
• to continually educate the staff;
• to expand resource information.
"We are going to sit down annually and have a general review with all staff of the topics we have discussed," Black says. "We’ll ask them how this has influenced them and the care they provide. We’ll also look at the actual ethical situations which have arisen and see if our policies have been used effectively."
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