Editorial: Broadening implementation of a preventive ethics approach.

We find the PE approach as part of the VA's IE program an excellent model from which all can learn. We have offered some additional issues for consideration on the basis of our own work and that of others. We hope that the combination of those ideas and the work of Foglia et al. will further advance the promotion and adoption of PE as a means to improve quality and minimize the occurrence of potentially harmful ethics conflicts.

Preventing ethics conflicts and improving healthcare quality through system redesign.

BACKGROUND: Ethics and quality care are common drivers for healthcare organisations. Both are based on ethics principles that are the foundation for quality, and are synergistic with the Institute of Medicine's six quality aims. This paper describes the relationship between ethics principles and the goals of improving quality, safety and value. It demonstrates how healthcare staff, quality improvement professionals and ethics committee members could apply a quality improvement framework to address and prevent ethics issues. DISCUSSION: Recurring ethics issues can have a detrimental impact on both the quality of patient care and the culture of a healthcare organisation. Clinical staff and ethics committee members traditionally respond to ethics issues using a reactive approach. Despite nascent interest in a system-oriented preventive approach to ethics issues, there is limited practical advice for ethics committee members regarding how to specifically implement a system redesign strategy. Using an illustrative case study, the authors demonstrate how to apply a recognised quality improvement framework, which focuses on clinical microsystems, to manage and decrease ethics issues--therefore enhancing the organisation's quality of care. CONCLUSION: An important step in enhancing quality and ethics aims would be for the organisation's staff, including quality improvement professionals and ethics committee members, to collaborate in fostering system redesign. The authors' aim is not to examine in detail a specific quality improvement approach or method; rather, they wish to highlight the synergy they believe exists between quality improvement efforts and organisational ethics issues.

Institutional attributes associated with innovation and improvement: results of a multisite study.

BACKGROUND: To date, no studies have explored why some teaching hospitals and health systems appear to offer a more fertile environment for innovation and improvement in the learning environment. As a consequence, little is known about the role of organizational attributes and culture in fostering innovation and improvements in settings where residents learn and participate in care, though these have been studied extensively in the general literature on organizations. AIMS: The goals of our study entailed (1) gathering ground-level observations on processes and common attributes; (2) disseminating this information for adoption and adaptation; and (3) exploring whether the current accreditation model may present barriers to institution- and program-level innovation. METHODS: We conducted a qualitative study of 4 institutions, successful in innovation and improvement in their learning environment, and sought to replicate the findings with a second group of 5 institutions. RESULTS: THREE THEMES EMERGED FROM THE INTERVIEWS AND SITE VISITS OF THE PARTICIPANTS IN THE ALPHA PHASE: (1) a structure and culture that promote integration and inclusion; (2) a recognition of the value of resident education to the institution; and (3) a learning organization rooted in the extensive use of data and ongoing change, improvement, and innovation. CONCLUSIONS: Some of the concepts identified in our small sample of "innovative" institutions could be relatively easily adopted or adapted by others that seek to enhance innovation and improvement in the learning environment. In contrast, the structural factors that characterized 3 of the 4 alpha participants, particularly the organization and compensation of faculty, may not be generalizable to many other institutions.

Publicly reporting comprehensive quality and cost data: a health care system's transparency initiative.

BACKGROUND: Transparency in health care, including the public reporting of health care results, is an expanding and unstoppable phenomenon. Health care systems have an opportunity to: (1) be proactive and accountable for the care they provide, (2) help patients learn more about their condition as a supplement to understanding the performance measures, and (3) use public reporting to foster process of care and outcome improvement initiatives. An overview is provided of the first 22 months of a transparency initiative at Dartmouth-Hitchcock Medical Center (DHMC). LAUNCHING THE TRANSPARENCY INITIATIVE: An interdisciplinary operations group works with the various clinical programs--both providers and patients--to identify what quality and cost measures are most desired by patients and what measures are the focus of the clinical program's internal measurement and reporting processes. The measures are presented on the DHMC Web site, with access to additional resources, such as clinical decision aids. DISCUSSION: A variety of factors are important to the transparency initiative--senior leaders' perceptions, risk management issues, resources required for the design and maintenance of the initiative, and developing both methodological protocols and technical systems.