National Ethics Teleconference

# The IntegratedEthics Initiative: What It Means for Your Facility

**January 26, 2005**

# INTRODUCTION

**Dr. Berkowitz:**

Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics
Consultation Service at the VHA National Center for Ethics in Health
Care and a physician at the VA NY Harbor Healthcare System. I am very
pleased to welcome you all to today\'s National Ethics Teleconference.
By sponsoring this series of calls, the Center provides an opportunity
for regular education and open discussion of ethical concerns relevant
to VHA. Each call features an educational presentation on an interesting
ethics topic followed by an open, moderated discussion of that topic.
After the discussion, we reserve the last few minutes of each call for
our \'from the field section\'. This will be your opportunity to speak
up and let us know what is on your mind regarding ethics related topics
other than the focus of today\'s call.

# 

# PRESENTATION

**Dr. Berkowitz:**

Today we will tell you about the IntegratedEthics initiative, an
exciting initiative that the Ethics Center is launching to promote the
development of IntegratedEthics programs at each facility. We will
describe for you why the initiative came to be, the needs that it will
meet in VHA facilities, what products are being developed, how the
initiative will roll out and what it will mean for your facility.
Joining me on today's call are two members of our Center staff, Dr.
Ellen Fox, the Director of our Center and Joel Roselin, the Center's
IntegratedEthics Coordinator. As always, we will provide plenty of time
after the presentation for questions and discussion.

Some of you in the audience already are familiar with the work we've
been doing on IntegratedEthics, but for others, this is the first you're
hearing of it. To set the stage I'd like to turn to Dr. Fox to tell us,
exactly what is IntegratedEthics?

#### Dr. Fox:

IntegratedEthics is an innovative national education initiative to
provide VHA facilities with the tools they need to transform their
traditional ethics committees into IntegratedEthics programs that better
match their needs. The National Center for Ethics in Health Care has
developed this initiative over several years and with extensive input
from the field to help bring VHA's health care ethics practices up to
speed with today's complex, changing health care environment. The most
important external measurements of health care quality (e.g., JCAHO
standards, Baldrige award criteria) have established that to achieve
excellence, health care ethics practices must be systematic and
pervasive.

The initiative addresses gaps in existing VHA ethics programs. Over
several years we have been collecting data about the needs of the field,
and we built this program to respond to those needs. We have tested
drafts of educational materials and tools with field staff, who have
provided useful and positive feedback. We have made sure to design a
program that can be customized by each facility to meet local needs and
work with preexisting structures. And we have taken care to ensure that
the project focuses, as VHA is focusing, on the increasing importance of
systems and organizational approaches to improvement.

We believe that implementing the IntegratedEthics model will make it
easier for you -- and people like you \-- to do what you're already
doing to improve ethical health care practices every day. We look
forward to working with and supporting all of you in this effort.

#### Dr. Berkowitz:

Joel, can you please tell us more about how the initiative was designed
to be practical?

#### Mr. Roselin:

The Center recognized that many demands compete for the time and
attention of field staff. That is why an IntegratedEthics program is
designed to be both effective and efficient. The idea is to enable you,
the facility staff, to make significant improvements in your ethics
program by investing a limited amount of your valuable time.

The program takes advantage of the existing strengths of our system -
quality improvement techniques, distance learning capabilities, our
well-developed IT infrastructure, and of course our dedicated facility
leaders and ethics committee members. The IntegratedEthics initiative
includes print materials, video courses, online modules, and a virtual
community to support and assist IntegratedEthics program teams charged
with leading their facility\'s effort toward organizational change.

#### Dr. Berkowitz:

In short, we're very conscious that organizational change takes a great
deal of commitment. We've tried, all along the way, to make sure that
your efforts will pay off and that you'll get a lot of "bang for the
buck" for the energy you put in!

This summer will mark a milestone in the development of the initiative,
and wanted you to hear about it early. In July we will begin
IntegratedEthics Workshops for some VISNs and/or groups of facilities.
At these workshops, a small team of four persons from each participating
facility will receive an orientation to the IntegratedEthics Initiative
and the IntegratedEthics program concept, as well as a toolkit filled
with learning materials and the tools needed for developing an
IntegratedEthics program at their facility.

**Mr. Roselin:**

In fact, Ken, letters will be going out this week to all VISN Directors,
VISN Ethics POCs, as well as ethics committee chairs explaining the
application process for applying for the demonstration phase of the
IntegratedEthics Initiative.

Dr. Berkowitz:

That's right Joel, but before we get into the details of the rollout and
what an IntegratedEthics program actually is, Ellen, can you tell us a
little more about what we know is the current state of ethics programs
in VHA and why they need to change?

Dr. Fox:

Let me paint a picture, if you will, of the state of ethics programs in
VHA. Ethics programs in VHA today essentially consist of the ethics
committee. Many of you will see your ethics committees reflected in my
comments. I would be remiss if I did not express my profound
appreciation for the work current committees do, very often without the
support or recognition they deserve. Our goal is to ensure that you have
more support \-- and the tools you need to assist and improve your
ethics committees.

Let me begin with some history and description. Ethics committees as we
know them began to form about 30 years ago, and today every VHA facility
has an ethics committee. In general, ethics committees focus on ethics
consultation, policies, and education. For the most part, ethics
committees tend to be reactive -- in that they wait for others to come
to them with ethical concerns, instead of proactively identifying and
addressing the institution's ethical problem areas. They tend to focus
on case-based ethical concerns -- that is, situations involving only a
few individuals at a given point in time, but they generally do not
focus much on systematically addressing the underlying organizational
causes that give rise to ethical concerns, or on dealing with broad
issues such as the organization's overall ethical environment and
culture. In addition, the ethics problems they do address typically fall
within a relatively narrow range of topics related primarily to the
domains of end-of-life care and shared decision-making. Ethics
committees in VHA are generally less confident in their ability to
address topics in areas such as resource allocation.

The volume of ethics consultation in VHA is high, higher in fact, than
the private sector. But, the processes used by ethics committees are
highly variable, even within a given institution. The activity is
resource intensive as many staff from multiple disciplines are involved
in the consultation process. Yet individuals who serve on ethics
committees generally receive very little formal training, and the
quality of their work is variable due in part to the 'collateral' nature
of their duties. Many ethics committees lack the support they desire
from senior leadership. And few facilities make serious efforts to
evaluate their ethics committees' effectiveness. For these reasons --
and despite the fact that the work of ethics committees is often
worthwhile and appreciated -- their efforts do not always lead to
overall quality improvement and lasting change.

I'm sure that this picture I've painted is one that many on the call
today will recognize.

#### Dr. Berkowitz:

So, we recognized that our ethics committees could become more
efficient, consistent and work proactively to make improvements at the
systems level, and decided to work to develop the appropriate training
and support to let me accomplish this. The Center began to collect data
through several surveys and other projects to identify specific needs
and gaps in existing ethics programs on which to base our plan for
improving ethics quality across VHA.

**Mr. Roselin:**

The process has been much more complex and has taken longer than
expected. What we anticipated would take one year has taken three
because one of the most important things we learned from our data
collection and field advisors was that understanding the concepts of
IntegratedEthics wasn't enough. To be practical, we needed to provide a
comprehensive set of tools and learning materials to each facility so
that they could create the organizational change consistently and
efficiently.

**Dr. Fox:**

In collaboration with our colleagues at Education Development Center, in
Boston, we formed field advisory groups, conducted pilot training and
worked with sites to test our developing programs and materials. In
fact, ethics staff from more than 25 facilities participated on our
various advisory groups, 6 VISNs have hosted pilot training programs and
literally hundreds of VA and non-VA ethics experts and health care
leaders have critically reviewed our training materials. I would like to
take a moment to thank all of you for your thoughtful and meaningful
contributions.

**Dr. Berkowitz:**

Of course we also drew on information from our Center Consultation
Service. The Center uses a web-based database for recording the process
and outcome of ethics consultations referred from the field and
performed by Center staff. It includes an evaluation process focused on
satisfaction with the consultation. There have been more than 550
consultation requests since the database was started in November 2001.

Dr. Fox:

All of this data collection has clarified for us the gaps in the current
system and identified ways for facilities to approach ethics improvement
systematically. This framework for ethics quality at the facility level
is the basis for the IntegratedEthics Programs. These IntegratedEthics
programs will apply the principles of quality improvement to transform
traditional ethics committees into IntegratedEthics programs that are
more responsive to today's complex health care needs. This concept of
IntegratedEthics has been shared with and endorsed by top leaders across
VHA, including the Under Secretary for Health.

Dr. Berkowitz:

So everything we know about the current ethics programs in VHA make us
believe that our system is ripe for change. The IntegratedEthics
initiative is designed to teach facilities how to apply principles of
quality improvement to evolve their current ethics committees into
IntegratedEthics programs that are better prepared to meet the needs of
a changing health care environment. Joel, there are 3 essential
functions of an IntegratedEthics program. Can you please describe them
for us?

Mr. Roselin:

The three essential functions of an IntegratedEthics Program are:

1.  Ethics Consultation, how to respond to ethical concerns in health
    care

2.  Preventive Ethics, how to address ethical issues on a systems level

3.  Ethical Leadership, how to promote a positive health care ethics
    environment

#  

Dr. Berkowitz:

And what will an IntegratedEthics program look like structurally?

Mr. Roselin:

What each facility sets up and how a facility chooses to carry out these
functions will vary according to local needs.

Dr. Berkowitz:

So the structure of an IntegratedEthics program reflects the adage "form
follows function."

Mr. Roselin:

Yes, the feeling is that each facility will know best what will work in
their environment; the only absolute requirements are that a top
facility leader be directly responsible for the IntegratedEthics
program's success and that the IntegratedEthics program work within the
three essential functions.

Dr. Berkowitz:

I think that next we should briefly look at each of the three essential
functions of an IntegratedEthics program a little more in depth and
clarify exactly what they are, and how attention to them will fill the
gaps and meet the needs. Joel...

Mr. Roselin:

Sure, Ken. Let's start with Ethics Consultation. While all VHA
facilities have ethics committees, we know that there is great
variability in terms of the knowledge, skills and processes used when
responding to consultation requests. Ethics consultation services
typically handle different types of consultations, including ethics case
consultation, requests for information or education, policy
clarification, document review, or ethical analysis. The function of
ethics consultation requires that the consultation team determine which
requests that come to them require a case consultation approach, which
require another type of ethical analysis or consultative response, and
which should be handled either by another facility mechanism or through
the second essential function, Preventive Ethics. We believe that for
ethics consultation services to be successful*,* they need adequate
*expertise, staff time, leadership support,* and *other resources.
Access, accountability, dissemination* and *evaluation* are additional
factors that should be established in *policy.*

Dr. Berkowitz:

As many of you know the Center is finalizing a comprehensive 70-page
"how to" primer for ethics consultation and will be disseminating it in
the next few months. When facilities participate in the IntegratedEthics
initiative, they will also receive more in depth training including a
comprehensive video course, print materials, evaluation tools, and tools
to help them improve their ethics consultation services. We're also
working with contractors right now to adapt our Center's electronic
consultation database system for field use. We hope to begin pilot
testing later this year and have it available for dissemination by the
fall.

Joel, the next IntegratedEthics program function, preventive ethics...

**Mr. Roselin:**

Ethics committees often find that the same problem pops up again and
again, such as questions about advance directives or surrogate decision
makers. Such recurrence often indicates a systemic problem. As part of
an IntegratedEthics program we've come up an approach for addressing
ethical issues at the systems level. We call this function Preventive
Ethics. We define preventive ethics as activities performed by an
individual or group in an effort to identify and correct systemic
*ethics issues* that give rise to ethical concerns. So, one might ask
what is an issue and how is it different than a case?

An ethics issue, like an ethics case, is a situation that raises an
ethical concern. Where an ethics case is an isolated situation involving
specific individuals and events, an ethics issue is an ongoing situation
involving organizational systems and processes. For example, an ethics
case might involve a conflict about withdrawing a ventilator from a
post-operative patient. An ethics consultation service might be asked to
help resolve the ethical concerns raised by that case. But what if the
ethics consultation service determined that this case is a recurrent
problem within the facility? What if this was not the first case of its
type that had come to the attention of the ethics consultation service,
but typical of many cases involving surgical patients? In such
circumstances, a specific response to a question about a case (i.e.,
ethics consultation) is inadequate. What is needed is systems-level
approach to the problem. This is the role of the Preventive Ethics
function.

Just as ethics consultation requires specialized expertise, the
Preventive Ethics function also requires expertise, resources and a
different approach. Preventive ethics involves: identifying quality
problems that give rise to ethical concerns, prioritizing among those
problems, studying the gap between current practice and best practices,
suggesting strategies and undertaking a plan to narrow the gap, and
evaluating the plan and adjusting as needed. A step-by-step approach to
preventive ethics is described in a 70-page primer that will be part of
the educational materials of the IntegratedEthics initiative.

Dr. Berkowitz:

Ellen, can you please tell us about the third IntegratedEthics program
function, Ethical Leadership?

Dr. Fox:

Having a mechanism to respond to ethics concerns - that is ethics
consultation - and addressing ethical issues proactively on a systems
level - that is, preventive ethics - is not enough. There is a third
element that is essential to a facility's ability to promote ethical
health care practices - and that is, promoting a positive health care
ethics environment. For example, your organization may have a lot of
ethics problems, but neither ethics consultation nor preventive ethics
approaches alone will work to address them if staff members do not feel
comfortable discussing their ethics problems or bringing them forward,
or if leaders do not view health care ethics as something that they need
to support.

Changing a facility's overall ethical environment is no small task. But
what the literature on organizational culture shows is that leaders play
a crucial role. That's what this third essential function of
IntegratedEthics is all about - what leaders should do to promote a more
positive health care ethics environment.

Ethical Leadership is a complex topic, with many different dimensions.
The IntegratedEthics approach focuses on specific leadership behaviors
that help foster a positive health care ethics environment - that is, an
environment that is conducive to ethical practices, and effectively
integrates health care ethics into the overall organizational culture.
How can leaders promote a positive health care ethics environment?
First, they must make it clear through their words and actions that they
think ethics is a priority. They need to communicate clear expectations
for ethical practice. They need to be fair and transparent in their
decision making practices. And they need to support their local ethics
program and all of its functions. The IntegratedEthics program Toolkit
will contain, among other things, a training video for leaders that
targets these specific leadership practices.

Ethical leadership also encompasses the notion that leaders much be
responsible - and accountable - for the organization's ethical health
care practices. So the ethical leadership function includes specific
evaluation tools for leaders to use to assess and monitor the facility's
status with respect to health care ethics, identify opportunities for
improvement, and measure the results of ongoing efforts to improve
health care ethics quality.

Dr. Berkowitz:

# Ellen, can you tell everyone how the IntegratedEthics initiative will roll out?

#  

**Dr. Fox:**

Well Ken, we're very excited. As was mentioned, letters will be going
out this week to invite facilities and VISNs to apply to be part of the
IntegratedEthics Demonstration Group and become part of the first
generation of VAMCs to implement the new paradigm for excellence in
health care ethics practices through the IntegratedEthics Initiative.

As with any organizational change initiative, successful implementation
will depend on the involvement of key leadership. Therefore, to be
considered for participation in the Demonstration Group, a facility must
assemble a multidisciplinary team of four individuals representing the
necessary combination of attributes for success: senior leadership,
clinical expertise, health care ethics expertise, and quality management
expertise.

The IntegratedEthics program leadership teams will attend a one-day
IntegratedEthics workshop in July or August of 2005 in Washington DC,
Salt Lake City or a central location convenient to the selected VISNs.

The one-day face-to-face workshop will lay the ground work for setting
up an IntegratedEthics program by demonstrating the need for improving
ethical health care practices; explaining the value of an integrated
approach; showing how an IntegratedEthics program differs from a
traditional ethics committee; identifying strategies to overcome
potential barriers to the implementation of an IntegratedEthics program;
and assisting participants as they formulate a plan for building an
IntegratedEthics program at their facility.

**Dr. Berkowitz:**

Joel, what will happen after the workshops?

**Mr. Roselin:**

After attending the workshop, the IntegratedEthics program champions --
as we're calling them -- will return to their respective facilities to
help facilitate the implementation of an IntegratedEthics program. Each
Demonstration Group site will receive an IntegratedEthics program
toolbox including tools and instructions for implementation, training,
communications, and assessment. These materials are designed to promote
distance learning and maximize program impact while minimizing ongoing
travel and training costs. In addition to these tools and materials,
Demonstration Group sites will receive proactive, ongoing technical
assistance and implementation support from the Ethics Center.

We expect that the facilities that participate in the Demonstration
Group will serve as role models and provide ongoing leadership to
successive IntegratedEthics participants. We also expect that
Demonstration Group sites will provide the Ethics Center with
information on their progress, to help us understand how the elements of
the IntegratedEthics toolbox are being used, and to document how they
cause the organization to change.

**Dr. Berkowitz:**

The orientation workshop will provide facilities with a practical
blueprint designed to maximize flexibility in the development of their
IntegratedEthics program. The interactive nature of the activities will
form a community of ethics champions working to create organizational
change across VHA. The Center will channel the energy gained through the
creation of shared wisdom to other ethics leaders, and IntegratedEthics
programs throughout VHA. All of this is very exciting, and probably to
some of you, a little daunting. We hope that this presentation has
sparked your interest in this initiative and ask that you share the
information with staff in your VISN and facilities, and invite you to
review carefully the materials that you will be receiving this week, and
apply to become a Demonstration Group site.

Again, applications for the IntegratedEthics Demonstration Group are
going out this week and are available on our Center's website and will
be due February 16, 2005. Facilities will be notified of their
acceptance by March 1, 2005.

**Dr. Berkowitz:**

I'm sure that there must be plenty of questions and comments, so please
speak up and let us know what's on your mind.

**Kola Danisa, Muskogee VA Medical Center:**

The IntegratedEthics program seems to have changed since I first heard
about several years back. What has prompted the new direction and
change?

Also, in many medical centers, there is no established process for
appointing individuals to the ethics committee. Yet, what you presented
implied the need for some sort of nomination and appointment process to
ensure that only people with the proper skills and qualifications can
serve on the ethics committee.

**Dr. Berkowitz**:

Those are two important questions. As Joel mentioned earlier, this
initiative has evolved over time in response to needs that we have
identified and comments we have received to be more useful and
practical. Some of the terminology you heard today may be different, but
many of the principles are still the same: to adopt a quality
improvement strategy for our local ethics programs.

**Dr. Fox:**

I think the point is a good one, that the selection of members to an
ethics committee is an important aspect to the likelihood of success for
that committee. We also want to emphasize the relationship between
leadership and the ethics program. It is important to have a reporting
structure in the organization where the entire ethics program responds
to success and responds to the top leader in the organization. We are
also focusing the leadership component of the training program on a
broad array of leaders, not just the top leader, because we think that
this is really essential to have an effect on the ethics environment and
culture. We have developed a leadership self-assessment tool that
facilities can use in a variety of ways to see where their leaders want
to work on different areas related to health care ethics and ask
themselves, "how am I doing in this area?"

**Steve Massopust, Black Hills Health Care System, Rapid City SD:**

I am chairman of the IntegratedEthics committee at Black Hills Health
Care System in Rapid City. I was fortunate enough to attend the July
2001 National Center for Ethics in Health Care meeting in Washington,
DC. We also had "Developing an IntegratedEthics program" in May 2002
with William Nelson. We developed at that time what is called a "hybrid
model" where we have representation from business compliance,
administration, HR, etc, and traditional ethics advisory committee. We
deal, at least theoretically, with organizational issues, policy issues,
and issues and analysis. But I have a couple of concerns. Because this
IntegratedEthics committee evolved from the traditional ethics advisory
committee, I think we still try to use the same methods, like the four
principle of bioethics in case consultation. I would be interested to
hear why those methods probably are not appropriate for an
IntegratedEthics committee, and how you would operate differently.

My second question is that there is getting to be a turf issue. Which
ethics committee do you consult, the ethics advisory committee, or the
IntegratedEthics committee. For example, a patient dying of cancer needs
an expensive non-formulary drugs. It's really an allocation of resources
of issues. Does the concerned staff member take that to the ethics
advisory committee or the IntegratedEthics committee, and how do we
education the staff about these two different types of committees?

**Dr. Berkowitz:**

Obviously, as we've said before, things have evolved over the past few
years, but let me get to the turf issues. Ideally we would prefer that
there not be turf issues---that everyone is working towards the same
goal to improve things. The circumstances you described to me, it sounds
much more to me like a case because it involves a specific patient and
group of individuals at a given point in time. If this type of question
were to recur, then that might be forwarded to the preventive ethics
group, or team, or function, who might be the same people, or many of
the same people. They would work at the issue from a systems level, but
the consultative response for that individual patient would clearly be a
case consultation for the consultation function. The underlying issues
might be taken up separately in the preventive function.

You also asked why do the approaches to case consultation need to be
different from other aspects of the IntegratedEthics program. I think
the materials that we have will make it clear why it will need to be
different, and underlying both the approach to consultation, and
prevention are the same ethical principles. So, in many cases, even
though the ethics are the same, the way you might proceed in different
situations, such as identifying gaps in current practices, different
ways to approach strategies, what process steps you might need to take
to work through a consultation, would probably be different than the
steps you might take to work through an issue, or a systems level look
at the same situation. In many ways, the ethics are the same, but the
approach is different, the parties that are involved might be different,
and that is stressed in the training materials.

**Mr. Roselin:**

The other question Steve raised as well has to do with how the
IntegratedEthics approach will affect the way people are currently doing
ethics consultation with the four principles of biomedical ethics.

**Dr. Massopust**:

That's right. I'm not sure that we would operate at the same level as we
are accustomed to do on the ethics advisory committee on a case
consultation.

**Mr. Roselin**:

It is important to say at this point that the IntegratedEthics
initiative is really an evolution, not a revolution in the way people
will be doing their ethics work. So, a case consultation that comes in
will be handled by a committee, and the principles of bioethics will
still apply. But, what we tried to do is create a system whereby people
can follow through from the beginning to the end of a consult with a
series of questions that need to be answered, some resources people use
to improve the overall quality of ethics consultation.

**Dr. Berkowitz:**

The consultation service is variable throughout the system, and is, at
times, inconsistent even within a facility. We believe that by providing
resources to consultants that need it, to really give them the expertise
and the background, and a standardized approach will enable them to
decide whether a consult is best handled by an individual, a team, or
the full committee. Once they've decided how they are going to approach
it, and they've identified the ethics question they are going to tackle,
then this material will instruct them on what things have to be
considered, which may be case specific information about the patient,
preferences, other people who are involved, as well as other kinds of
ethics knowledge that is needed to think systematically through the
case. Sometimes that will be suited more for the principles approach, at
other times it is better suited for casuistry, sometimes a consult will
call for mediation techniques, or conflict resolution techniques. And
all this different ways of analyzing and looking at a case are important
for a consultant to have in his or her repertoire. So, the consultation
function is really trying to give those consultants who are doing
consultation a framework to make sure they have the adequate competency,
skills, and knowledge set to continually improve their ethics
consultation.

**Jan Briggs, Louis Stokes VAMC, Cleveland OH:**

You have used a lot of interesting phrases, one of which was brought up
in leadership as the necessary attributes for success. Who defines those
attributes, and how have those attributes been arrived at? Who defines
the ethical principles? What are the definitions, and how where they
arrived at? The way you are describing it is vague.

**Dr. Fox:**

We relied heavily on the published literature, and in the case of
ethical leadership, we looked to everything from the public
administration literature to the business ethics literature.

**Ms. Briggs:**

So this is largely a business model?

**Dr. Berkowitz:**

We've certainly drawn on the business ethics model, but I think it is a
new model specifically designed for health care. If you are equating a
business model with a quality improvement model or a systems model, then
in that sense, perhaps. But it is not intended to be a business model.
It is intended to be a health care ethics paradigm.

.

**Ms. Briggs:**

Let me give you a question, and tell me how this applies. Say we are
looking at an HIV positive patient who has a spotty record of adherence
and he is asking for viagra, and that question is brought before the
ethics committee. How would your model handle this?

**Dr. Berkowitz:**

Actually, our model would apply to that question, assuming there was an
appropriate environment and an appropriate program in place, if it was a
specific question about a specific patient, that would be handled
probably as it would be now through the consultative function of the
IntegratedEthics program, either through an individual consultant or a
team of consultants. Once the case was worked through, if there was a
pattern of recurring cases, or, if there was a perception that this was
an issue that deserved a response beyond a response from just those
involved in the case, then it could be referred to the preventive
function, would then try to decide if it was an appropriate priority
concern for their group. Their response would be a systems-level
response, which is very different than what we have right now.

**Dr. Fox:**

I think part of what is being assumed is that there is a question that
is being brought to the IntegratedEthics committee and they are being
asked to respond. The philosophy of the IntegratedEthics program is to
get away from this reactive stance, and to be more proactive behind the
scenes, so that if a problem comes to the attention of the
IntegratedEthics program, they already have a good idea of what to do
with those problems, and they have an understanding of the background
conditions that give rise to those problems.

One way we have of thinking about this is that the current model of
ethics consultation is like the tip of the iceberg. But, what is being
missed are all the systemic contributors to individual cases that need
to be addressed. The IntegratedEthics approach is meant to take on those
systemic issues as well, and foundational to that is facility
leadership.

**Dr. Berkowitz:**

And we didn't mean to imply that the only way an issue can come to the
attention of the preventive function is through the consultation
function. Leaders or other staff may be aware of an ethics issue that
could be improved if addressed, and they might bring that independently
to the preventive ethics function.

# FROM THE FIELD

**Dr. Berkowitz:**

Now I want to turn to our "From the Field" segment, where we take
comments from our listeners on ethics topics [not]{.underline} related
to today's call. Please remember, no specific consultation requests in
this open format, but I invite you now to make your comments on other
ethics-related topics, or to continue our discussion on the
IntegratedEthics Initiative.

**Linda Williams, Little Rock VAMC, North Little Rock, AR:**

The way our ethics committee is organized is that we have subcommittees.
We have consultation, policy, education, research and review. And we do
try to bring clusters of cases and solve those at a more systems level.
How is that different from what you are talking about?

**Dr. Berkowitz:**

In fact, some of it may not be very different at all. If you have set up
your program and you are approaching the three IntegratedEthics
functions, that is good. There is a good chance that the educational
materials that we put together would still be really beneficial.

**CONCLUSION**

**Dr. Berkowitz:**

Well, as usual, we did not expect to conclude this discussion in the
time allotted, and unfortunately we are out of time for today\'s
discussion. We will post on our Web site a very detailed summary of each
National Ethics Teleconference. So please visit our Web site to review
today\'s discussion. We will be sending a follow up email for this call
that will include the links to the appropriate web addresses for the
call summary and the CME credits.

We would like to thank everyone who has worked hard on the development,
planning, and implementation of this call. It is never a trivial task
and I appreciate everyone\'s efforts, especially, Dr. Fox, Mr. Roselin,
Nichelle Cherry, and other members of the Ethics Center and EES staff
who support these calls.

-   Let me remind you our next NET call will be on Tuesday, February 22,
    2005 from 12:00 -- 1:00 pm EST. Please look to the Web site at
    vaww.va.gov/vhaethics and your Outlook e-mail for details and
    announcements.

-   I will be sending out a follow-up e-mail for this call with the
    e-mail addresses and links that you can use to access the Ethics
    Center, the summary of this call and the instructions for obtaining
    CME credits.

-   Please let us know if you or someone you know should be receiving
    the announcements for these calls and didn\'t.

-   Please let us know if you have suggestions for topics for future
    calls.

-   Again, our e-mail address is: vhaethics@va.gov.

Thank you and have a great day!