collection: MODULE 2 MODULE 3 MODULE 4 ETHICS ISSUE 2: Professionalism in Patient Care—Truth Telling 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 6. Current Ethics Practice “Is” The quality manager for surgical services found a number of instances in which adverse events that caused harm that should have been disclosed to patients or personal representatives were not disclosed. VHA Handbook 1004.08 Disclosure of Adverse Events to Patients There is an unwavering ethical obligation to disclose to patients harmful adverse events that have been sustained in the course of care, including cases where the harm may not be obvious, or where there is potential for harm to occur in the future. Exclusion(s): Patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal Adverse events that cause harm to patients on surgical services should be disclosed to the patient or personal representative [unless patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative]. Numerator: __________________ Denominator: Method: Sample size:
ETHICS ISSUE 5: Ethical Practices in Everyday Workplace—Ethical Climate 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 5. Current Ethics Practice “Is” The ethics consultation service’s annual report for FY 20XX found that none of their consultations were about ethical concerns affecting nonclinical staff. IntegratedEthics (IE) Program Requirements Just as IE addresses all three levels of ethics quality, it also deals with the full range of ethics concerns that commonly arise in health care—not just clinical concerns. Exclusion(s): None Ethics consultation services should address ethical concerns affecting nonclinical staff. Numerator: __________________ Denominator: Method: Sample size: Time frame for data collection:
Handout 4.2 Metrics and Current Ethics Practice—Answer Keys ETHICS ISSUE 1: Shared Decision Making with Patients—Advance Care Planning 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 6. Current Ethics Practice “Is” A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. VHA Handbook 1004.2 Advance Care Planning and Management of Advance Directives VHA Handbook states that additional information about advance directives and/or assistance in completing forms must be provided for all patients who request this service. Exclusion(s): Patients who change their minds about their requests for assistance, who withdraw from the Health Care System, or who now lack capacity. Primary care patients who request assistance with completing an advance directive should receive it [unless patients change their minds about their request for assistance, withdraw from the Health Care System or who now lack decision-making capacity]. Numerator: The number of primary care patients provided with assistance as measured by a note template completed by a social worker or someone equally trained __________________ Denominator: Total number of primary care patients who requested assistance with completing an advance directive Method: Record review Sample size: 30 Time frame for data collection: 1 week 3 ÷ 30 = 10% Currently, 10% of primary care patients who have a documented request for assistance with completing an advance directive receive it.
MODULE 2 MODULE 3 MODULE 4 ETHICS ISSUE 2: Professionalism in Patient Care—Truth Telling 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 6. Current Ethics Practice “Is”
The quality manager for surgical services found a number of instances in which adverse events that caused harm should have been disclosed to patients or personal representatives were not disclosed. VHA Handbook 1004.08 Disclosure of Adverse Events to Patients There is an unwavering ethical obligation to disclose to patients harmful adverse events that have been sustained in t he course of care, including cases where the harm may not be obvious, or where there is potential for harm to occur in the future. Exclusion(s): Patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative. Adverse events that cause harm to patients on surgical services should be disclosed to the patient or personal representative [unless patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative]. Numerator: Number of adverse events that caused harm to patients that were disclosed to patients or personal representatives as measured by a note template completed by the provider __________________ Denominator: Total number of adverse events that caused harm to patients on surgical services Method: Record review Sample size: 100% Time frame for data collection: Past 6 months 13 ÷ 20 = 65% Currently, 65% of adverse events that cause harm to patients on surgical services are being disclosed to the patient or personal representative. MODULE 2 MODULE 3 MODULE 4
ETHICS ISSUE 3: Ethical Practices in End-of-Life Care—Other 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 5. Current Ethics Practice “Is” Nursing staff on the acute care medical floor have reported that they are having an increasingly difficult time persuading physicians to round on dying patients waiting to be discharged to another care setting—and that patients continue to ask when the doctor will be in to visit and wonder why the doctor has stopped coming every day. American Medical Association Statement on Care Facility Policy on Management of Information Patients should be able to trust that their physician will continue to care for them when dying. If a physician must transfer the patient in order to provide quality care, that physician should make every reasonable effort to continue to visit the patient with regularity, and institutional systems should try to accommodate this. Facility policy states that patients should receive the same care by all treating providers, and patients on acute care floors should be seen daily. Exclusion(s): Patient does not wish to have his/her physician round on a daily basis. Physicians should continue to round daily on dying medicine patients that are waiting to be discharged to another care setting [unless Patient does not wish to have his/her physician round on a daily basis]. Numerator: Number of dying patients who were visited daily by a physician while waiting to be discharged to another care setting __________________ Denominator: Total number of dying patients waiting to be discharged to another care setting Method: Observation Sample size: 20 patients Time frame for data collection: 5 days 30 ÷ 100 = 30% Currently, 30% of physicians round on dying patients at least once per day while the patient is waiting to be discharged to another care setting. MODULE 2 MODULE 3 MODULE 4
ETHICS ISSUE 4: Ethical Practices in Business and Management—Business Integrity 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 5. Current Ethics Practice “Is” Coding staff are not routinely consulting physicians to clarify conflicting or ambiguous documentation in the patient’s electronic health record, and therefore enter inaccurate information. American Health Information Management Association Code of Ethics VHA Handbook 1907.03 Health Information Management Clinical Coding Program Procedures Health information management professionals shall not participate in, condone, or be associated with dishonesty, fraud and abuse, or deception including: Assigning codes without physician documentation Coding when documentation does not justify the procedures that have been billed Coding an inappropriate level of service Miscoding to avoid conflict with others VHA policy states that when there is conflicting or ambiguous documentation in the patient’s record, the patient’s physician(s) must be consulted for clarification. Exclusion(s): Coding staff should ensure accurate coding by reviewing conflicting or ambiguous documentation with the physician of record. Numerator: Number of records with ambiguous or conflicting documentation where physicians were not contacted _________________ Denominator: Number of records with ambiguous or conflicting documentation Method: Record review Sample size: 100 Time frame for data collection: 1 week 12 ÷ 100 = 12% Currently, physicians are not being contacted for 12% of the records with ambiguous or conflicting documentation.
1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric 5. Current Ethics Practice “Is” The ethics consultation service’s annual report for FY 20XX found that none of their consultations were about ethical concerns affecting nonclinical staff. IntegratedEthics (IE) Program Requirements Just as IE addresses all three levels of ethics quality, it also deals with the full range of ethics concerns that commonly arise in health care-not just clinical concerns. Exclusion(s): None Ethics consultation services should address ethical concerns affecting nonclinical staff. Numerator: Number of ethics consultations that affect non-clinical staff __________________ Denominator: Total number of ethics consultations Method: Consultation records Sample size: 100% Time frame for data collection: 1 year 0 ÷ 32 = 0% Currently, 0% of ethics consultations have affected staff. MODULE 2 MODULE 3 MODULE 4
Handout 4.3 Method Strengths (+) Weaknesses (–) Existing data (Health or other record) + Available + Inexpensive + Metric already determined + Commonly used in health care + Most health care staff are experienced in finding and extracting data from health record – Sometimes off the mark (collected for a different purpose) – Uncertainty about representativeness of data – Variability in the consistency of clinicians’ documentation in medical records – Data depends on reliable documentation process Observations + Direct measurement + Objective + Able to obtain qualitative information after observation period + Contextualized + Most health care staff already experienced in “observing” – Time limited (possible problems with representativeness) – Hawthorne effect (social desirability) – Requires development of “observations checklist” to define what observers will be looking for – Possible reliability problems if more than one observer Interviews: Telephone + Able to obtain a large sample + Able to obtain complete data + Able to ask about personal information, i.e., knowledge of respondent – Requires development of a set of interview questions and probes – Possible barriers due to language and/or hearing challenges – Hawthorne effect (social desirability bias) – Training requirements for interviewer(s) Interviews: Face-to-face + Able to collect complete data + Knowledge of respondent + Controlled environment + Good response rate – Hawthorne effect (social desirability bias) – Training requirements for interviewer(s) – Challenge with sensitive questions Focus groups (6–8 individuals) + Obtains brush stroke information + Affirms/refutes ideas easily + Synergy (new ideas) may occur in the group process – Obtains brush stroke information – May not be representative – Need skilled facilitator – Role, levels of authority, gender, etc., may affect openness – Threats include domination of air time, side-tracking Surveys: Mail + Standardized + Able to obtain data from a large – Needs cognitive testing to minimize the risk of participants misinterpreting the meaning of the
number of respondents + No need for interviewers + Convenient for respondents + Allows for anonymity with sensitive questions questions – Fear about lack of confidentiality – Lower response rates may threaten representativeness – Risk of incomplete data – Reading and language barriers – Uncertainty about who is responding – Respondent may consult other sources (e.g., Internet, colleagues) before responding; however, this may not be a bad thing if you are looking for facts, not opinions which sometimes may be required Surveys: Internet + Able to obtain data on large numbers of respondents + No need for interviewers + Less expensive + Convenient for respondents + Speedy + Able to have automated data entry and results reporting (e.g., aggregated statistics) – Needs cognitive testing to minimize the risk of participants misinterpreting the meaning of the questions – Non-response bias – Often requires knowledge of the Web – Requires computer literacy – Barriers may exist pertaining to language and physical disabilities – Respondent may consult other sources (e.g., Internet, colleagues) before responding; however, this may not be a bad thing if you are looking for facts, not opinions
Handout 4.6 Instructions Describe the 5 core elements of your data collection plan and be prepared to share your thinking with the rest of the group. You should base your plan on the information in the chart below and on other handouts and notes you may have taken during this session. ETHICS ISSUE 2: Professionalism in Patient Care—Truth Telling 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” The quality manager for surgical services found a number of instances where adverse events that caused harm that should have been disclosed to the patient or personal representative were not disclosed. VHA Handbook 1004.08 Disclosure of Adverse Events to Patients There is an unwavering ethical obligation to disclose to patients harmful adverse events that have been sustained in the course of care, including cases where the harm may not be obvious, or where there is potential for harm to occur in the future. Exclusion(s): Adverse events that cause harm to patients on surgical services should be disclosed to the patient or personal representative [un less patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative]. MODULE 2 MODULE 3