1 / 40

CHE Ethics Champion Series Ethics & Quality

CHE Ethics Champion Series Ethics & Quality. Mark Repenshek, PhD Health Care Ethicist Columbia St. Mary ’ s Senior Director, Ethics Integration and Education Ascension Health. Context for Ethics Consultation. Columbia St. Mary ’ s Health System Three Acute Care Hospitals ~722 beds

niyati
Download Presentation

CHE Ethics Champion Series Ethics & Quality

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. CHE Ethics Champion SeriesEthics & Quality Mark Repenshek, PhD Health Care Ethicist Columbia St. Mary’s Senior Director, Ethics Integration and Education Ascension Health

  2. Context for Ethics Consultation • Columbia St. Mary’s Health System • Three Acute Care Hospitals ~722 beds • 64 physician clinics with ~400+ employed physicians; 1100 affiliated physicians • FY 2011: 22.970 hospital discharges; 72,344 ED visits; 24,459 OP Hospital Visits • Ethics Consultation Service: • Two Medical Staff Ethics Committees • One PhD Ethicist; Ad Hoc Consultation Model/Advisement Model • Ethics Consultation for Database: • 523 consults from January 2003 through December 2011 • Cases: • Identified ethical reason for consultation • Identified discipline requesting • CSM Ethics consultation service engaged • Ethics consultation documented • Ethics recommendations made to case

  3. Clinical Ethics Consultation: Columbia St. Mary’s Health System CSM Ethics Consultation for Database: 523; January 2003 - December 2011* *HIPAA Waiver Granted from 2003-2011 Data Set CSM Research Oversight Committee No. of Consults/Literature: 255; Swetz, et al. Mayo Clinic Proceedings 2007; 82(6): 686-691. 150; Schenkenberg. HEC Forum 1997; 9;147-158. 104; La Puma, et al. JAMA 1988;260: 808-811. 31; Forde & Vandvik. J Med Ethics. 2005; 31:73-77. 39; Waisel, et al. Mil Med 2000; 165:528-532.

  4. Ethics Consultation at CSM

  5. Largest requestor group by percent of tConsults: Physicians (n=57/91 2011) Ethics Consultation at CSM

  6. Largest requestor group by discipline of tConsults: Hospitalists (n=30/91 2011) Nursing (n=16/91 2011) Case Management (n=12/91 2011) Ethics Consultation at CSM

  7. Largest “Reason for Request” of tConsults: Shared Decision-Making (n=48/91 2011) Professionalism (n=21/91 2011) Ethics Prac in EoL (n=15/91 2011) Ethics Consultation at CSM

  8. Ethics Consultation at CSM

  9. Greatest ”Level of Assistance” of tConsults: Rec. Best Course (n=54/91 2011) Specify Range of Options (n=22/91 2011) Clarification of Ethics Policy (n=14/91 2011) Ethics Consultation at CSM

  10. Clinical Ethics Consultation: Columbia St. Mary’s Health System/ per Month 2008 Implementation of Standardized Methodology for Clinical Consultation Group A; n=169 Group B; n=151

  11. Hypothesis No.1: Increasing the Integration of the clinical ethics program will bring consultation closer to admission

  12. Hypothesis No.2: As ethics consultation occurs closer to admission, consultation will be more advisory than conflict resolution

  13. Ethics and Quality: Continuous Quality Improvement in Ethics Consultation

  14. Hypothesis No.3: An integrated clinical ethics program creates opportunities for demonstrable organizational/clinical change in practice Assumptions: • Identified ethical reason for consultation • Identified discipline requesting • CSM Ethics consultation service engaged • Ethics consultation documented • Ethics recommendations made to case Inclusion Criteria: • Acuity of patient population: ICU • Complexity of patient population: 2 hospitalizations within past six months for same primary DRG Exclusion Criteria: • No retrospective reviews--level of consult request

  15. Clinical Consultation Changing Organizational Practice? • Ethics Tracker Database • August 2006-October 2006 • 3 consults related to Intra/peri-operative Code Status • MD Association Guidelines • American College of Surgeons: ST-19 Statement on Advance Directive by Patients: “Do Not Resuscitate” in the Operating Room • American Society of Anesthesiologists: Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders • Goal: Initiate opportunity within existing pre-procedure processes for MD to address with patient or designated surrogate(s) existing directives to limit the use of resuscitation procedures • Dept of Surgery follow-up re: Ethics Case Consultations • Grand Rounds follow-up with CME Accountabilities for CQI

  16. Clinical Consultation Changing Organizational Practice • Medical Staff Pre- Procedure Checklist Adopted: • Dept Anesthesiology • Dept Surgery • Dept Orthopedic Surgery • Dept of Medicine (Exec Council)

  17. Clinical Consultation Changing Organizational Practice • Ethics Tracker Database • 2003-2008 Reason for Consultation (R for C) • Discernment of Patient’s Wishes/Best Interests highest aggregate--39.6% of ethics consultation • Increasing R for C from 22% to 44% of cases from 2004-2006. • ACP Literature • Hammes and Rooney. “Death and End-of-Life Planning in One Midwestern Community.”Arch Intern Med 1998;158: 383-390. • 85% Subjects with written AD • 81% AD in the medical record • National Data: ~15% subjects with written AD The SUPPORT Principal Investigators. JAMA 1995;274:1591-1598 • CSM Data: ~12% subjects with written AD • Goal: Improve Advance Care Planning Program throughout outpatient sites to move end-of-life decision making away from the end-of-life

  18. Clinical Consultation Changing Organizational Practice ACP Program Implementation Increased ACP utilization from 12% to 59% throughout CSM NOTE: 2006-2007 “Discernment of Patient’s Wishes/Best Interests” as Reason for Consult in Ethics Tracker dropped from 41% to 24% of total

  19. Communicating Ethics Quality: The Dashboard

  20. Trending Ethics Quality: The Dashboard

  21. Conclusions • Ethics consultation can be measured both in process and impact--No free pass on quality measures; • Conversation has and must continue to move from whether to measure to how to measure; • Rigorous debate on whether these methodologies are on target in terms of capturing process/impact of ethics consultation

  22. Title Slide What is to be learned from Ethics Case Consultations Joann Starr, PhD, MSW System Director of Ethics

  23. GOALS: • All case consults documented in EMR • Accessible to Clinicians • Ensure quality of documentation/consults • Enhance quality of care by using aggregate data

  24. CRITICAL STEPS : • Engage ethics leaders • Clarify documentation format • Ensure process consistency/ quality

  25. DEFINING KEY ELEMENTS FOR DOCUMENTING Information about ethical dilemma: • Reasons for request • Ethically relevant medical/social history • Discussion with family/staff • Ethical Analysis • Was consensus achieved • What was the recommendation • What was the implementation plan • What will happen next • Follow-up Plan • Logistics: • Type of consultation • Date and time • Requestor • Requestors discipline • People present

  26. 63% Physician = Purple 13% Nurse = Green 2% Social Worker = Blue 2% Chaplain = Turquoise 3% Family = Burgundy 76% Physician = Purple 14% Nurse = Green 3% Social Worker = Blue

  27. CHRISTUS Health Reason for Consult August 2012 Thru July 2013 7% Appropriate Surrogate, Yellow 19% Code Status, Red 6% Communications Problems, Lime Green 10% D-M Capacity, Light Green 32% Goals of Treatment, Turquoise 6% Medical Futility, Orange 1% Pain/Symptom Management, Light Blue 1% Patient and Surrogate Disagree, Blue 1% Pediatric Issue, Blue 1% Religious Values/Treatment Conflict, Blue 7% Transition/Discharge Plan, Purple 9% Withdraw/Withhold Treatment, Lavender N=125 consults N+82 Pts

  28. So What Question? Why is this important? • Establish learning community for ethics services which can support consultation members being prepared and comfortable • Consult members know that they are participating in quality ethics case consultations • Improve the quality of patient care and decrease crisis consultations

  29. Ethics Tracker: The Ascension Health Experience JP Slosar, PhD Vice President, Ethics Integration and Education

  30. Background • After months, if not years, of insistence from Dr. Repenshek that “data are important,” we decided to get serious • The nature of what we do at the system level is very different from the role of the clinical ethicist “on the ground” • What do we need to know? What do we want to be able to demonstrate? What value do we seek from the data?

  31. Background • Benefits • Efficiency of reporting to different stakeholder groups, e.g. Board, OoP and Sponsors • Demonstrate the integration of ethics into both operations and clinical care • Ensure consistency of analyses, conclusions and recommendations across “consultants” • Increase proficiency (“stop re-inventing the wheel”) • Target services to demonstrated – not simply perceived – needs of our Health Ministries

  32. Service Components

  33. Church Relations

  34. Committee Work

  35. Consultation

  36. Education

  37. Conclusions • Okay, Okay, already, Data are important • Value goes way beyond reporting: • Quality of Ethics Services Provided • Roadmap for Integrating Ethics • Tangible metrics of Catholic identity • Spread and dissemination of leading practices • Future Goal: Systemwide database interfacing local HM and system level databases on intranet to provide “self-service, automated ethics consultation”

More Related