The Joint Commission (TJC) retired two requirements in its revised hospital accreditation standards, effective as of February 2023: “The hospital follows a process that allows staff, patients, and families to address ethical issues or issues prone to conflict” (LD.04.02.03) and “Ethical principles guide the hospital’s business practices” (LD.04.02.03, EP 1).1
Subsequently, TJC released an update.2 Effective Aug. 27, 2023, the Element of Performance for Standard LD.04.02.03 (“Ethical principles guide the hospital’s business practices”) was updated to state: “The [hospital] develops and implements a process that allows staff, [patients], and families to address ethical issues or issues prone to conflict.”
“I am heartened to learn that The Joint Commission updated and reinforced the clinical ethics standard as an element of performance,” says Kayhan Parsi, JD, PhD, HEC-C, president of the American Society for Bioethics and Humanities (ASBH). “This is a step in the right direction and shows the clinical ethics community that The Joint Commission takes seriously the practice of clinical ethics and views it as a vital part of healthcare in the U.S.”
As it initially appeared the ethics requirements were eliminated, many in the field of clinical ethics were concerned TJC was taking less of an explicit interest in ethics work in hospitals. Renee McLeod-Sordjan, DNP, PhDc, FNAP, co-authored a paper on this topic.3 “From my experience, Joint Commission believed that hospitals were compliant, and the standard was never an issue. However, clearly, there was little thought to address who was responding to the ethical issues,” says McLeod-Sordjan, director of the division of medical ethics at Northwell Health System and chair of the Northwell Health System ethics review committee.
During surveys, McLeod-Sordjan recalls TJC did not ask about the knowledge and skills of individuals performing ethics work. Also, surveyors did not ask for clarification on the mechanisms used to resolve ethical issues at the hospital. “Little was ascertained as to whether ethical issues were resolved administratively vs. ethics consultant vs. ethics committee. It was not outlined or questioned,” McLeod-Sordjan recounts.
McLeod-Sordjan would like to see the institutions TJC accredits held accountable to demonstrate the individuals responsible for resolving business or clinical ethics issues do have the skills and competence to facilitate ethical resolution, dialogue, and decision-making. McLeod-Sordjan and colleagues recommend a multilayered approach. “First and foremost, the quality of ethics response and consultation should be guided by the [Healthcare Ethics Consultant-Certified] standard created by ASBH,” McLeod-Sordjan says.
McLeod-Sordjan and colleagues recommended other TJC changes. These include holding organizations accountable for using national standards in their process for resolving ethical dilemmas, encouraging organizations to meet specific criteria for documenting and assessing quality of ethics consults, and including some individuals during onsite surveys with expertise in evaluating ethics consultation quality.
McLeod-Sordjan and colleagues also would like to see TJC require organizations to disclose data on the types of ethical conflict in the institution and the patients requiring ethics consultation, expect organizations to quantify equity and social justice ethical concerns, and use that data to inform quality improvement efforts, and require organizations to maintain a minimum number of FTEs who perform ethics consultations.
“The Joint Commission, at present, gives no insight into the model of ethics consultation that meets the standard. Nor do they suggest an educational requirement,” McLeod-Sordjan notes. Thus, hospitals have little incentive to put resources into ethics work, which in turn means clinical ethicists cannot maintain a singular focus on ethics work. “Instead, physicians, nurses, and other interdisciplinary roles devote a portion of their clinical role to ethics as an ‘add-on,’” McLeod-Sordjan says.
In terms of TJC potentially retiring ethics standards, “that’s the wrong direction,” argues Thomas V. Cunningham, PhD, MA, MS. “The Joint Commission needs to be taking more of an interest in clinical ethics. Included in that would be the need to have a competent workforce and the need to meet certain staffing criteria to demonstrate that adequate personnel are available to respond to ethical issues that arise in hospital care.”
A 1992 standard from the then-Joint Commission on Accreditation of Healthcare Organizations required hospitals to establish a “mechanism to consider ethical issues in patient care.”4 This requirement resulted in most hospitals creating ethics committees. “Over time, I think the standards have gotten weakened and muddied,” says Cunningham, bioethics director at the Kaiser Permanente West Los Angeles Medical Center.
Cunningham and colleagues recently argued ethics standards are vague compared to standards for clinical areas such as infection prevention and control.5 “There is a relationship between The Joint Commission standards, their oversight, and hospital practices,” Cunningham says.
If TJC were to weaken ethics standards, it would send a message that ethics is not a priority, according to Cunningham. On the other hand, if TJC strengthened expectations for ethics, or added new, more specific requirements, hospitals would receive the message that ethics is a priority.
“If they were clear about their expectations for professional competency and adequate staffing for quality clinical ethics practices in the hospital setting, hospitals would respond accordingly,” Cunningham offers.
Some hospitals might respond by hiring ethicists. Other hospitals might pay more attention to who is responsible for clinical ethics practices and auditing ethics consults.
“At the least, this likely would result in more protected time for people involved in clinical ethics practices and more awareness of whether they have met minimum standards for competence — namely, holding the HEC-C certification,” Cunningham suggests.
According to Kathryn Petrovic, MSN, RN, director of TJC’s department of standards and survey methods, “medical ethics is absolutely an important part of clinical care, which The Joint Commission has always supported.”
Currently, TJC’s standard simply requires hospitals to maintain a process to address ethical issues. “It does not call for special expertise from the surveyors. And, frankly, they do not bring particular insight,” says Cynthia Barnard, PhD, MBA, vice president of quality at Northwestern Memorial HealthCare.
Reflecting on 30 years of TJC surveys, Barnard says surveyors usually do not address ethics at all. In most cases, surveyors did not ask a question about the ethics process. Occasionally, surveyors verified the hospital maintained an ethics process and confirmed staff and patients could access it. Surveyors did so by examining the hospital’s ethics policy, committee structures, and charters.
Barnard says no one ever asked her to provide additional background on the training or qualifications of ethicists or ethics committee members. Surveyors never asked questions about any ethics consults during the tracer methodology part of the survey (where surveyors follow the path of specific patients through the entire healthcare experience).
“Nor have the surveyors asked for our evaluation to ensure that the process is effective, evidence-based, and high-quality,” Barnard shares.
TJC visits a hospital formally just once every three years. “The survey process is necessarily high-level,” Barnard observes.
With hundreds of standards to evaluate, surveyors tend to focus on the highest-risk and highest-impact areas. “There is considerable pressure from the field to limit new standards to those which support evidence-based practice contributing to quality and safety. This is obviously important to ensure resources are allocated appropriately,” Barnard says.
Hospitals, too, are working with limited resources and multiple competing priorities. Many lack the resources for a full-time, credentialed ethicist. “There is not sufficient supply at this time,” Barnard laments. “But it is not adequate to rely on the current, rather casual, model of ethics that is in place at many hospitals.”
Often, a few clinicians seek some additional education before taking on the role of ethics consultant on a volunteer basis.
“The Joint Commission could play a role in elevating the professionalism and value of ethics programs nationally with some enhanced standards, encouraging formal attention to best practices and evaluation — and evolving toward the possibility of more rigor over time,” Barnard suggests.
REFERENCES
1. The Joint Commission. Select retired and revised accreditation requirements. Dec. 20, 2022.
2. The Joint Commission. Updated requirement for addressing ethical issues. Joint Commission Perspectives. May 2023.
3. McLeod-Sordjan R, Swidler R, Fins J. Where is clinical ethics in the revised hospital accreditation standards? The Hastings Center Bioethics Forum Essay. March 24, 2023.
4. Joint Commission on Accreditation of Healthcare Organizations. Accreditation manual for hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1992.
5. Aaron B, Crites JS, Cunningham TV, et al. Hospital ethics practices: Recommendations for improving Joint Commission standards. Jt Comm J Qual Patient Saf 2022;48:682-685.
The Joint Commission could play a role in elevating the professionalism and value of ethics programs nationally with some enhanced standards, encouraging formal attention to best practices and evaluation — and evolving toward the possibility of more rigor over time.
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