Handout 6.2 Ethics Issue Root Cause 1, 2, or 3? Strategy 1 Strategy 2 Strategy 3 A chart audit revealed that advance directives of chronic dialysis patients are not accurately completed (e.g., missing information), making it unclear whether the documents were valid and accurately reflected patient preferences about future care if they lost decision-making capacity. It is unclear who is responsible for ensuring that the advance directives are completed. Translate the institution’s information booklet on dialysis into Spanish, since that is the native language of many staff and patients involved in dialysis treatment. Circulate a flow chart among the dialysis treatment team, showing all the steps in the process. Highlight where the step for completing advance directives comes in. Revise the job description of the dialysis social worker to coordinate the advance care planning process. Patients discharged from the institution against medical advice (AMA) are frequently discharged without prescriptions or follow-up clinic appointments, and previously scheduled appointments are automatically cancelled. An AMA discharge generates an auto-cancel feature for all future appointments. Remove the feature for future appointments for all AMA discharges. Interview AMA patients to determine if they are unable to follow doctors’ orders, and might as well be discharged. Conduct a staff survey on the institutional culture to find out how and why it supports punitive action by physicians against patients. Staff members with ethical concerns have not reported their concerns so they can be addressed. Most staff do not know how to locate or use the tool for referring ethical concerns to the institution’s consultation service. Develop printed materials explaining how to navigate the service’s new Web site. Hold focus groups to see how many staff believe that submitting their ethical concerns on the Web will get them in trouble. Train and certify department heads in the use of the tool for referring ethical concerns to the consultation service.
Change Concepts* Eliminate things that are not used Eliminate multiple entry Reduce or eliminate overkill Reduce controls on the system Recycle or reuse Use substitution Reduce classifications Remove intermediaries Match the amount to the need Use sampling Change targets or set points Synchronize Schedule into multiple processes Minimize handoffs Move steps in the process close together Find and remove bottlenecks Use automation Smooth workflow Do tasks in parallel Consider people as in the same system Use multiple processing units Adjust to peak demand Match inventory to predicted demand Use pull systems Reduce choice of features Reduce multiple brands of same item Give people access to information Use proper measurements Take care of basics Reduce demotivating aspects of the pay system Conduct training Implement cross-training Invest more resources in improvement Focus on core process and purpose Share risks Emphasize natural and logical consequences Develop alliances and cooperative relationships Listen to customers Coach customers to use a product/service Focus on the outcome to a customer Use a coordinator Reach agreement on expectations Outsource for “free” Optimize level of inspection Work with suppliers Reduce setup or startup time Set up timing to use discounts Optimize maintenance Extend specialist’s time Reduce wait time Standardization (create a formal process) Stop tampering Develop operational definitions Improve predictions Develop contingency plans Sort produce into grades Desensitize Exploit variation Use reminders Use differentiation Use constraints Use affordances Mass customize Offer product/service anytime Offer product/service anyplace Emphasize intangibles Influence or take advantage of fashion trends Reduce the number of components Disguise defects or problems Differentiate product using quality dimensions Change the order of process steps Manage uncertainty, not tasks *Langley, G. J. et al: The Improvement Guide. 2nd edition. San Francisco: Jossey-Bass, 2009