CHE Ethics Champion Series Ethics & Quality

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

27. 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

28. 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

31. 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

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

33. 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?

34. 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

35. Service Components

36. Church Relations

37. Committee Work

38. Consultation

39. Education

40. 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”