By Stacey Kusterbeck
To improve, ethics programs need to know how they compare to other ethics programs. However, a lack of benchmarking data in the bioethics field remains a frustrating obstacle. “Benchmarking is a hallmark of well-managed businesses in any industry. The goal is to model practices after those of the best performers in the field,” says Jonathan Darrow, SJD, LLM, JD, MBA, a former professor at Harvard Medical School.
For the field of bioethics in particular, says Darrow, “it can be important not to succumb to a belief in public health exceptionalism — the misguided view that healthcare is somehow immune from resource constraints, conflicts of interest, operational vulnerabilities, or other ordinary business dynamics. Just as in any industry, continuous surveying, periodic reevaluation of internal practices, and an openness to continuous improvement are essential.”
Developing comparative data “is key to advancing clinical ethics as a profession. We have an obligation to be accountable for our work and its effects in a way others can review and learn from,” asserts Stowe Locke Teti, MA, HEC-C, a senior clinical ethicist at Inova Health System and instructor of medicine at UVA School of Medicine.
Benchmarking data allows ethics program to meet the first commitment of the American Society for Bioethics and Humanities’ code of ethics — to be competent.1 “Competence requires some form of performance assessment — some means by which an ethics consult service can measure its work in comparison to others. Ethics programs need input from beyond their own walls and institutional culture. Otherwise, we are each in echo chambers of our own making,” says Teti.
A group of clinical ethicists, including Teti, formed the Clinical Ethics Consultation Benchmarking Collaborative (CECBC) in 2021, to develop a robust empirical dataset that ethics consult services could use to benchmark their activities. “This has been a long-sought goal. But it has been difficult to achieve, due to the heterogeneity of ethics consultation practices and consult documentation,” explains Teti.
First, the CECBC leadership team had to determine what data to collect about ethics consult services. The first hurdle was the lack of consistency in how basic terms were defined. “Even the idea of what counts as an ethics consult is the subject of much debate,” says Teti.
At some hospitals, even an informal phone call is viewed as an ethics consult. At other hospitals, only a formal process including meetings with key stakeholders is considered an ethics consult. Ultimately, the CECBC leadership decided against narrowly defining what constitutes an ethics consult. “We all come from different perspectives. We agreed not to let the perfect be the enemy of the good,” says Mark Repenshek, PhD, vice president of ethics and church relations at Ascension. The ethicists allowed participants to answer questions according to the definition at their institutions. “We decided that here’s this thing called a clinical ethics consult, and we trust that those in the field understand what that is, regardless of how they define it. So, the thing that you call in your system a clinical ethics consult — that’s what we’re going to call a clinical ethics consult. So, tell us how many of those you do!” says Repenshek.
Another challenge is that ethics programs have widely differing structures. Many small community hospitals rely strictly on volunteer clinicians. Large medical centers often have multiple FTEs [full-time employees] doing ethics work. “Ethicists may have management, leadership, or educational capacity — all those aspects of their role are beyond solely providing ethics consults. What’s an FTE at one place may not be an FTE at another,” says Repenshek.
These factors make it impossible for the database to provide a truly apples-to-apples comparison. “While recognizing those limitations, the dataset still offers some meaningful information. We decided to jump in and say, let’s capture these fields of data. Let’s accept the fact that we may define things differently, and get the project going, and see what the result looks like,” says Repenshek.
In its third year (2023), CECBC collected data from 465 hospitals (compared to 330 hospitals in its first year, 2021) representing 15,725 ethics consults (compared to 9,753 in 2021) across 106,786 staffed beds (compared to 69,300 in 2021) and 121.8 FTEs (compared to 66.2 in 2021) dedicated to ethics consultation.
The CECBC database includes a wide range of hospital sizes and types. “Our dataset closely matches the distribution of U.S. hospitals by both licensed bed count and hospital type. We also collect data from hospitals that report zero FTEs dedicated to ethics consultation and even zero consults,” notes Teti.
CECBC also collects demographic data about hospitals. This allows users to investigate a set of hospitals similar to their own for more direct comparisons. “The data [are] not drawn from a random sample, but rather a sample of hospitals and health systems that are — or wish to be — active in clinical ethics. In that sense, it’s aspirational, which is in keeping with the idea of benchmarking performance,” observes Teti.
Ethicists can use the dataset in different ways depending on their unique needs. Teti offers these examples:
- A critical access hospital with a volunteer model could use the database to make the case for funding. As members of CECBC, the hospital could use the data to show that more than 40% of critical access hospitals with active ethics programs have funding for ethics consultation.
- A new ethics program could use the database to evaluate which model of ethics consultation best fits their needs. Ethicists could see that over 90% of academic medical centers use a single consultant model, whereas 73% of community hospitals use a consult team.
“Performance data and actionable insights allows clinical ethics to function like any other consult service in the hospital — which means the program is seen as integral to our mission, vision, and values,” says Teti. At Inova, ethicists have used this data to identify which units call ethicists more or less frequently and to identify the primary ethical issues on given units, allowing ethicists to tailor education. “We use the data to show the manifold benefits our service provides. We have gained additional staff as a result, and seats at tables we otherwise might not be at,” says Teti.
At Ascension, ethicists have been tracking data for about a decade across their different sites and markets. “We can make a fair number of claims internally about what we do, and even do some comparative analysis. It’s helpful for the work we do internal to Ascension, but the data [are] somewhat limited once we move outside our organization. This data-gathering project allows us to be a part of a continuous quality improvement journey in a very different way,” says Repenshek.
Repenshek sees an intrinsic value in the data collection effort for the field of bioethics. “To take that next leap and just throw data out there, and say, ‘Here’s what we are doing,’ — that’s a pretty big shift in our field. And it’s something I’m really excited to see,” says Repenshek. Repenshek says ethics programs can use the data in these ways:
- To determine if the hospital is an outlier. Is a 200-bed hospital getting only a few consults a year? That volume is not on par with what other ethics programs are seeing. “Then you have to start asking questions on why you are not somewhere in the neighborhood of hospitals that are around the same size,” says Repenshek.
- To answer questions from hospital leaders about the value of ethics work. “We need to be thinking of how we can quantify the work that we do. Leaders are asking, and we have to be able to respond,” says Repenshek.
Ethicists may view the importance of their work as self-evident, since they consult on the most complex cases and most vulnerable patients. That reasoning is a tougher sell in today’s healthcare environment. “Hospital leaders want to know: What’s your value add? If you don’t have the data to at least start examining that, in a data-rich environment, a hospital leader is going to say, ‘Well, why not?’” says Repenshek.
Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.
Reference
1. Tarzian AJ, Wocial LD; ASBH Clinical Ethics Consultation Affairs Committee. A code of ethics for health care ethics consultants: Journey to the present and implications for the field. Am J Bioeth. 2015;15(5):38-51.
To improve, ethics programs need to know how they compare to other ethics programs. However, a lack of benchmarking data in the bioethics field remains a frustrating obstacle.
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