Combining Ethics Inquiry and Clinical Experience in a Premedical Health Care Ethics Internship.

PROBLEM: The professional formation of physicians begins in the premedical years, and educators are now recommending that medical ethics and humanities courses be considered essential components to becoming a physician rather than elective prerequisites for medical school admission. As a result, questions have arisen about how to teach students ethical reasoning skills before their professional training, as they have limited opportunities now to develop these skills and the related competencies in a real-world medical context. APPROACH: The authors describe Santa Clara University's Health Care Ethics Internship (HCEI), an undergraduate college experience that emphasizes ethical inquiry and immerses students in health care settings to foster deep learning. The HCEI includes mentored clinical rotations integrated with classroom inquiry into ethical theory, structured reflection, and professional development considerations. A survey of former students (academic years 2001-2002 to 2017-2018) explored their perceptions of these program components and the impact of the experience on their preprofessional readiness, career choice, and professional capabilities. OUTCOMES: Of 185 former students who could be contacted, 89 (48.1%) completed the survey. Students reported that the HCEI: (1) assisted them in gaining admission to medical school, (2) had a positive influence on their career decisions, (3) increased their professional capabilities, (4) helped them develop preprofessional competencies, (5) gave them knowledge and experience they used in their personal and professional ethical decision making, and (6) increased their moral sensitivity and ethical responsibility. NEXT STEPS: Integrating clinical rotations into ethics education exposes premedical students to real-world ethical questions, helps them develop a nuanced understanding of a health care career, and prepares them for the medical school admissions process. Other universities should consider implementing a similar program to prime their students for continued professional and moral development during medical school and residency.

Facilitating ethical quality improvement initiatives: Design and implementation of an initiative-specific ethics committee.

Like all facets of healthcare practice, quality improvement (QI) should be conducted in an ethically responsible manner. For methodologically complex QI, accountability and thoughtful ethical monitoring might be particularly important. Yet, access to ethical guidance for QI, as opposed to research, is often limited. Available mechanisms tend to be ill-equipped to accommodate the rapid cycle nature of QI, and monitoring standards for QI are not well defined. Providing appropriate ethical guidance for complex, multi-site QI initiatives can be especially challenging, as the body providing guidance must be familiar with QI methods, recognize the competing interests of stakeholder groups, respond to numerous requests, and understand the initiative's design. This case report describes our solution-an initiative-specific QI Ethics Committee that provided ethical guidance and consultation to a Veterans Administration QI initiative employing local innovations and a centralized evaluation. Enhanced by multiple tables, we discuss structuring and staffing the committee, the committee's role, functions and activities, requests for ethics guidance, and our strategy applying initiative-specific ethical principles to guide recommendations. Supported by feedback obtained from stakeholder interviews, we share key insights regarding the value of: • Clarifying and marketing the committee's role to users. • Reconciling conflicting interests between site-based team members and cross-site evaluators. • Separating ethics guidance from regulatory oversight. • Addressing the ethics of evaluative design. • Adjusting the intensity of the committee's work over time. • Creating tangible products. Our approach shows promise in supporting the ethical practice of methodologically complex QI, especially in institutions that lack applicable ethics monitoring mechanisms. Building on this approach, other complex QI initiatives can develop effective and feasible methods to protect participants from unintentional ethical lapses.

Preventive ethics: addressing ethics quality gaps on a systems level.

BACKGROUND: Preventive ethics (PE) is a key component of IntegratedEthics (IE), an innovative model developed by the Veterans Health Administration (VA)'s National Center for Ethics in Health Care which establishes a comprehensive, systematic, integrated approach to ethics in health care organizations. Since early 2008, IE has been implemented throughout all 153 medical centers and 21 regional networks within the US Department of Veterans Affairs (VA) health care system. ISSUES: A STEP-BY-STEP APPROACH TO ETHICS QUALITY IMPROVEMENT: PE employs a systematic, step-by-step process improvement approach called ISSUES: Identify an issue, Study the issue, Select a strategy, Undertake a plan, Evaluate and adjust, and Sustain and spread. After the ethics quality gap is described, a measureable and achievable improvement goal based on the gap is developed. One of the most challenging aspects of describing an ethics quality gap is to establish an appropriate ethical standard on which to base the operational definition of best ethics practice. PRACTICAL STEPS TO DEVELOPING A PREVENTIVE ETHICS FUNCTION: Within the VA's IE model, PE is situated as a subcommittee of the IE council, which is chaired by the facility director (equivalent to a hospital chief executive officer) and oversees all aspects of the organization's ethics program, including ethical leadership, ethics consultation, and PE. Each VA medical center is required to have a PE team led and managed by a PE coordinator and may need to address ethics issues across the full range of health care ethics domains. CONCLUSIONS: The VA's IE model establishes a robust conceptual framework, along with concrete tools and resources, to integrate PE concepts into the day-to-day operations of a health care organization and is directly transferrable to other health care organizations and systems.

Ethical challenges within Veterans Administration healthcare facilities: perspectives of managers, clinicians, patients, and ethics committee chairpersons.

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration (VA) facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients (n = 32) and managers (n = 38); semi-structured interviews with managers (n = 31), clinicians (n = 55), and ethics committee chairpersons (n = 21). Data were analyzed using content analysis. Managers reported that the greatest ethical challenge was fairly distributing resources across programs and services, whereas clinicians identified the effect of resource constraints on patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondent's role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions.

Priority setting and the ethics of resource allocation within VA healthcare facilities: results of a survey.

BACKGROUND: Setting priorities and the subsequent allocation of resources is a major ethical issue facing healthcare facilities, including the Veterans Health Administration (VHA), the largest integrated healthcare delivery network in the United States. Yet despite the importance of priority setting and its impact on those who receive and those who provide care, we know relatively little about how clinicians and managers view allocation processes within their facilities. PURPOSE: The purpose of this secondary analysis of survey data was to characterize staff members' perceptions regarding the fairness of healthcare ethics practices related to resource allocation in Veterans Administration (VA) facilities. The specific aim of the study was to compare the responses of clinicians, clinician managers, and non-clinician managers with respect to these survey items. METHODS: We utilized a paper and web-based survey and a cross-sectional design of VHA clinicians and managers. Our sample consisted of a purposive stratified sample of 109 managers and a stratified random sample of 269 clinicians employed 20 or more hours per week in one of four VA medical centers. The four medical centers were participating as field sites selected to test the logistics of administering and reporting results of the Integrated Ethics Staff Survey, an assessment tool aimed at characterizing a broad range of ethical practices within a healthcare organization. RESULTS: In general, clinicians were more critical than clinician managers or non-clinician managers of the institutions' allocation processes and of the impact of resource decisions on patient care. Clinicians commonly reported that they did not (a) understand their facility's decision-making processes, (b) receive explanations from management regarding the reasons behind important allocation decisions, or (b) perceive that they were influential in allocation decisions. In addition, clinicians and managers both perceived that education related to the ethics of resource allocation was insufficient and that their facilities could increase their effectiveness in identifying and resolving ethical problems related to resource allocation. CONCLUSION: How well a healthcare facility ensures fairness in the way it allocates its resources across programs and services depends on multiple factors, including awareness by decision makers that setting priorities and allocating resources is a moral enterprise (moral awareness), the availability of a consistent process that includes important stakeholder groups (procedural justice), and concurrence by stakeholders that decisions represent outcomes that fairly balance competing interests and have a positive net effect on the quality of care (distributive justice). In this study, clinicians and managers alike identified the need for improvement in healthcare ethics practices related to resource allocation.

The ethics of using quality improvement methods in health care.

Quality improvement (QI) activities can improve health care but must be conducted ethically. The Hastings Center convened leaders and scholars to address ethical requirements for QI and their relationship to regulations protecting human subjects of research. The group defined QI as systematic, data-guided activities designed to bring about immediate improvements in health care delivery in particular settings and concluded that QI is an intrinsic part of normal health care operations. Both clinicians and patients have an ethical responsibility to participate in QI, provided that it complies with specified ethical requirements. Most QI activities are not human subjects research and should not undergo review by an institutional review board; rather, appropriately calibrated supervision of QI activities should be part of professional supervision of clinical practice. The group formulated a framework that would use key characteristics of a project and its context to categorize it as QI, human subjects research, or both, with the potential of a customized institutional review board process for the overlap category. The group recommended a period of innovation and evaluation to refine the framework for ethical conduct of QI and to integrate that framework into clinical practice.

The Health Insurance Portability and Accountability Act Privacy Rule: a practical guide for researchers.

BACKGROUND: The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, intended to address potential threats to patient privacy posed by the computerization and standardization of medical records, provides a new floor level of federal protection for health information in all 50 states. In most cases, compliance with the Privacy Rule was required as of April 2003. Yet considerable confusion and concern remain about the Privacy Rule and the specific changes it requires in the way healthcare providers, health plans, and others use, maintain, and disclose health information. Researchers worry that the Privacy Rule could hinder their access to health information needed to conduct their research. OBJECTIVES: In this article, we explain how the final version of the Privacy Rule governs disclosure of health information, assess implications of the Privacy Rule for research, and offer practical suggestions for researchers who require access to health information. CONCLUSION: The Privacy Rule is fundamentally changing the way that healthcare providers, health plans, and others use, maintain, and disclose health information and the steps that researchers must take to obtain health data. The Privacy Rule requires researchers who seek access to identifiable health information to obtain written authorization from subjects, or, alternatively, to demonstrate that their research protocols meet certain Privacy Rule requirements that permit access without written authorization. To ensure continued access to data, researchers will need to work more closely than before with healthcare providers, health plans, and other institutions that generate and maintain health information.

Nurses Improving Care for Healthsystem Elders (NICHE): using outcomes and benchmarks for evidenced-based practice.

This article describes Nurses Improving Care for Healthsystem Elders (NICHE), a project begun in 1992 with four pilot hospitals. These pilot hospitals gathered baseline data using a geriatric institutional assessment profile (GIAP) with a pre- and postdesign to capture changes in staff attitudes, knowledge, and perceptions of the care of older adults. Based on the success of the pilot effort, NICHE, now in its eighth year, has evolved into a program that involves 32 health systems comprising 105 hospitals nationally. To date, more than 10,000 GIAPs have been collected by NICHE hospital staff. All NICHE settings are able to benchmark their GIAP data against comparable institutions (eg, urban, rural, university, community settings) to understand how they compare and then interpret the data at their unique sites. The opportunities for continuous quality improvement through the NICHE program are described.