Preventive Ethics

1. Preventive Ethics Beyond the Basics

2. Module 6 Identifying Change Strategies to Address an Ethics Quality Gap

3. Learning Objectives • Identify major causes and contributing causes for a specific ethics quality gap. • Select those causes that contribute most to a particular ethics quality gap. • Identify change strategies to address specific causes of an ethics quality gap.

4. ISSUES Link SELECT a Strategy Identify the major cause(s) of the ethics quality gap Brainstorm possible strategies to narrow the gap Choose one or more strategies to try

5. Storyboard Progression STUDY the Issue Refine the improvement goal to reflect the ethics quality gap (include a time frame, if possible) Reality check • Starting point • Seriousness • Environment • Challenge Achievable Goal: 90% Increase the percentage of primary care patients who receive requested assistance with completing an advance directive from 10% to 90% by 4th quarter, 20XX. Exclusions: Patients who change their minds about their request for assistance, who withdraw from the Health Care System, or who now lack decision-making capacity. Advance Directives Issue

6. Select a Strategy • Determine major cause(s) of ethics quality gap and draw “fishbone” or other cause-and-effect diagram. • Brainstorm possible strategies to narrow gap. • Choose one or more strategies to try based on likelihood of success, expected net benefit, and resources required to implement the strategy. • Explain rationale.

7. Identify Major Causes • Meet with a team of process and content experts. • Write a “cause question.” • Review your process flow diagram. • Brainstorm major causes of the ethics quality gap. • Select the top causes (2 or 3). • Drill down to the root cause for selected causes.

8. Identify Major Causes • Meet with team of process and content experts. • Process experts—specific, hands-on knowledge of processes resulting in gap • Content experts—deep knowledge of ethics issue and ethical practice

9. Identify Major Causes • Write “cause question.” • What causes… • …[current ethics practice]?

10. Identify Major Causes • Write “cause question.” Current Ethics Practice 10% of primary care patients who had a documented request for assistance with completing an advance directive received it. Cause Question What causes primary care patients who have requested assistance to not receive assistance with completing an advance directive? Cause Question: Shorthand What causes patients to not receive assistance with completing an advance directive?

11. Fishbone Diagram Equipment Process What causes primary care patients to not receive assistance with completing an advance directive? Policy People

12. Identify Major Causes • Review process flow diagram. • Start identification of potential causes.

13. Process Flow Diagram

14. Identify Major Causes • Brainstorm major causes of ethics quality gap. • Focus on quantity. • Withhold criticism. • Combine and build on one another’s ideas. • Keep it brief.

15. Identify Major Causes • Brainstorm major causes of ethics quality gap. Cause Question: What causes socks to disappear from the laundry?

16. Group Activity InstructionsHandout 6.1-A (5 min) • Choose recorder and spokesperson. • Draft cause question. • Brainstorm major causes and record on flipchart pages.

17. Identify Major Causes • Select top causes (2 or 3). • Distinguish “vital few” from “trivial many.” • Pareto Effect aka 80:20 Rule. • Vote on “vital few.”

18. Identify Major Causes Voting on “Vital Few” • Give 3 votes per team member. • Team members can use votes for different causes or 1 cause. • Team leader tallies votes and rank orders the causes. • Team discusses top 3–5 vote getters and comes to consensus about top 2 or 3 causes.

19. Identify Major Causes • Drill down to root causes. • Use “5 Whys” to get to root causes of ethics quality gap. • Decide on top “root causes” for ethics quality gap.

20. Drill Down to Root Cause 5 Whys Root Cause

21. 5 Why’s Why was request not received by the Social Worker? Because the unit clerk sends requests to the social work department’s general fax number Why is the request sent to the general fax number? Because that is what is specified in the policy Why does the policy require requests be sent to general fax number? Because social work coverage for primary care is completed by multiple social workers.

22. 5 Why’s Why is primary care covered by several social workers? The workload in primary care does not support a specific designated social worker so coverage is provided when the clerk finds someone who is available

23. Group Activity InstructionsHandout 6.1-B (10 min) • Choose recorder and (different) spokesperson. • Select 2 or 3 “vital few” causes, using voting technique. • Create 2 or 3 new flipchart pages, each with selected top cause as page heading. • Use 5 Whys to identify root causes for each top cause. Record your 5 Whys questions and answers under each major cause.

24. Process for Selecting Strategies to Address Root Causes • Match strategy with cause. • Assess strategy strength. • Assess strategy impact/effort.

25. Match Strategy to Cause Cause question: What causes computers to be routinely left unattended with patients’ personal health information visible on the screen? Root cause: Time-outs not being set on computers Change strategy: Set computers to auto time-out after XX minutes of no use.

26. Match Strategy to Cause Ethics Issue: Private patient information (i.e., full name, date of birth, and complete social security number) is included on all patient food items stored in a community refrigerator accessed by patients, visitors, and staff. Root Cause: Label maker programmed to include private patient information. Change Strategy: Educate unit staff on safeguarding private patient information. Actual Change Strategy Selected: Program and produce new labels that exclude unnecessary patient identifiers, and educate staff on implementing the new process to protect private patient information.

27. Activity InstructionsHandout 6.2 (2 min) • Choose 1 strategy for each of 3 issues on handout. • Prepare to share rationale for your choices with whole group.

28. Ethics Issue: Advance Directives Ethics Issue: A chart audit revealed that advancedirectives 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. Root Cause: It is unclear who is responsible for ensuring that the advance directives are completed. Change Strategy: Revise the job description of the dialysis social worker to coordinate the advance care planning process.

29. Ethics Issue: AMA Patients Ethics Issue: Patients discharged from the institution against medical advice (AMA) are frequently discharged without follow-up clinic appointments, and previously scheduled appointments are automatically cancelled. Root Cause: An AMA discharge generates an auto-cancel feature for all future appointments. Change Strategy: Remove the auto-cancel feature for future appointments for all AMA discharges.

30. Ethics Issue: Staff Ethical Concerns Ethics Issue: Staff members with ethical concerns have not reported their concern so it can be addressed. Root Cause: Most staff do not know how to locate or use the Web-based tool for referring ethical concerns to the institution’s consultation service. Change Strategy: Develop printed materials explaining how to navigate the service’s new Web site.

31. Process for Selecting Strategies to Address Root Causes • Match strategy with cause. • Assess strategy strength: • Stronger • Intermediate • Weaker • Assess strategy impact/effort.

32. Assess Strategy Strength

33. Assess Strategy Strength

34. Assess Strategy Strength Intermediate Strong Intermediate Intermediate Weak

35. Group Activity InstructionsHandouts 6.3 and 6.4 (5 min) • Choose (different) spokesperson. • Select 1 root cause and identify change strategies to address it. • Determine if strategies are weak, intermediate, or strong.

36. Process for Selecting Strategies to Address Root Causes • Match cause with strategy. • Assess strategy strength. • Assess strategy impact/effort: • Impact/Effort Grid

37. Impact/Effort Grid Highest Priority High (HL) Quick Wins (Focus on these as much as you can) (HH) Major Projects (Complex/Time Consuming) IMPACT (LL) • Fill Ins (Quick Fix) • (LH) Thankless Tasks (Time Wasters) Low High EFFORT Place each improvement strategy in the quadrant that best reflects the impact expected and the effort it would require.

38. Impact/Effort Grid Highest Priority High (IMPACTHIGH) Auto alert addresses time frame. Template ensures info available. (EFFORT HIGH) Template may require large time commitment to create. (IMPACTHIGH) Action stops information from being available. (EFFORT LOW) Doesn’t require much time or many resources to reprogram labeler. IMPACT Low High EFFORT Place each improvement strategy in the quadrant that best reflects the impact expected and the effort it would require.

39. Group Activity InstructionsHandouts 6.4 and 6.5 (5 min) For each strategy listed on Handout 6.4: • Assign impact level (H or L). • Assign effort level (H or L). • Answer question: Which strategy will you recommend to leadership for implementation? Explain.

40. Storyboard Progression SELECT a Strategy Determine the major cause(s) and rank order them based on those that contribute most to the ethics quality gap. • Delay in process within social work due to having to find a social worker to complete the consult • Unclear delineation on who is to determine if patient wants information on updating or completing an advance directive • Information provided to patient has large amount of variation Brainstorm possible strategies to address top causes. Delay in process within social work due to having to find a social worker to complete the consult • Appoint social workers to specific primary care clinics. • Develop coverage schedule for primary care clinics. • Have clerk rotate consults through all social work staff. Advance Directives Issue

41. Takeaways Identifying change strategies to address an ethics quality gap • Identifying major causes • Selecting causes • Identifying change strategies • Selecting strategies

42. Module 6 Questions?