ASBH Core Competencies and Future Ethicist Certification: Our Community Standard of Practice?

1. ASBH Core Competencies and Future Ethicist Certification:Our Community Standard of Practice? Dawn Seery, RN, MA, D. Bioethics System Ethicist Mount Carmel Health System, Columbus, Ohio

2. Objectives • Describe trends in establishing core competencies for those acting as clinical ethics consultants. • Identify organizational and professional challenges to a certification or credentialing process. • Discuss implications for ethics consultants within Catholic health care organizations.

3. The Need for Competency “Patients, families, surrogates, and health care providers deserve assurance that when they seek help sorting through the ethical dimensions of health care, ethics consultants are competent to offer that assistance. Given the nature and goals of ethics consultation, consultants must possess certain skills, knowledge, and character traits to perform competently.” ASBH 1998. Task Force for Standards on Bioethics Consultation

4. Core Competencies … (1998, 1st Ed) Defining Ethics Consultation Core Skills Core Knowledge Character traits Organizational Ethics Evaluation Special Obligations

5. Healthcare Ethics Consultation(HCEC) “ [A] service provided by an individual or a group to help patients, families, surrogate, health care providers, or other involved parties address uncertainty or conflict regarding value-laden issues that emerge in health care.” ASBH Core Competencies (1998) , p3 “The ethics facilitation approach is most appropriate for consultation…[It] is informed by the context in which ethics consultation is done and involves two core features: identifying and analyzing the nature of the value uncertainty and facilitating the building of consensus.[It] recognizes the boundaries for morally acceptable solutions” p 6-7

6. Core Skills for Ethics Consultation: • Ethical assessment skills: • Gather data • Identify the relevant values of involved parties • Identify and justify a range of morally acceptable options and their consequences • Process skills: • Identify key decision-makers • Set ground rules for formal meetings • Engage in creative problem solving • Document consults and elicit feedback • Interpersonal skills • Ability to listen well and to communicate • Ability to represent the views of involved parties • Ability to recognize and attend to relational barriers • ASBH Core Competencies (1998)

7. Ethics Facilitation Professional and social ideal: • Resolution process should be respectful of all parties involved and their interests • Identify issues; aid effective communication • Develop plan within ethical and legal bounds 2) Recommendations should comport with relevant literature from bioethics, medicine, judicial opinions, and institutional policy.

8. Ethics Facilitation • Clarify the specific ethics question • Gather relevant information • Clarify relevant concepts and normative issues • Identify the specific ethics issue • Identify a range of ethically acceptable options within the context and the rationale for each option

9. ASBH Recommends… • “Voluntary guidelines” • “Rejection of certification” • increases the risk of displacing providers and patients as the primary moral decision-makers at the bedside • Undermines disciplinary diversity • Institutionalization of a particular view of morality • Standardized testing would have to be shown • Requires a bureaucracy to manage it • ASBH Core Competencies (1998)

10. Drawbacks of Accreditation “The emergence of accredited educational programs could promote dominance of a particular moral view or technical approach, have an adverse effect on disciplinary diversity, and imply a degree of professionalization that is, in the opinion of the Task Force, premature at best.” Core Competencies (1998) p32

11. Developments • ASBH Advisory Committee on Ethics Standards • (ACES) needs assessment for a code of ethics: • 61% support professional code • 17% objected • 2007 Fox et al. survey of 500 hospitals: • 36,000 consultations • 29,000 individuals performing consultations – ‘wholly unregulated’ • 45% learned independently, without supervision or formal training • 41% trained by experienced consultant • 5% has completed a fellowship or degree program in ethics • ASBH announces its support for the professionalization • of clinical ethics consultants • 2009 CHA’s Theology and Ethics Committee conversation

12. Strengthening The Quality of Ethics in Catholic Health Care • 2009 -2011: • CHA in collaboration with Ascension Health develop a resource to strengthen • the identity and integrity of Catholic health care ethics to effectively carry on the • healing mission of Jesus: • 1) underscore the importance of ethics in the organization • 2) identify the range of ethics services that can promote and support • the identity and integrity of an organization and those within it • 3) recommend standards for promoting the highest quality performance • in each mode of ethics service • 4) provide tools that will assist in the pursuit of ever greater excellence • in the ethics services provided.

13. Core Competencies … (2011,2nd Ed) Defining Consultation Core Skills Core Knowledge Attributes Evaluation Emerging Practice Standards

14. …First, do no harm • “It is the clinical subspecialty where unqualified HCE consultants have the highest potential to directly harm patients and families” • “The Task Force considers clinical ethics case consultation in which the HCE consultant interacts with a patient/family and documents activities in the patient’s medical record to be where the stakes are often the highest.” • Core Competencies,2nd Ed., p3

15. Ethical Dimensions of an Emerging Professional Practice • Distinctive social role occupied by ethics consultants • Ethics consultants can influence the clinical care of patients, the behavior of health professionals toward families and toward each other, and the impact of clinicians and healthcare institutions

16. Attributes, Attitudes, and Behaviors Attributes, Attitudes, and Behaviors: • Tolerance, patience, compassion • Honesty, self-awareness of limitations • Courage • Prudence, humility • Leadership • Integrity

17. “Surveys of ethics committees over the past ten years, including a survey of committees in Catholic hospitals, support the abundant anecdotal evidence that there is no shortage of opportunities for improvement in the organization, competency, functioning, and effectiveness of many if not most committees.” Striving for Excellence in Ethics (2014), p 21

18. Professionalization “To the extent that the ultimate commitment of this [ASBH]Task Force is to improve and maintain the quality of HCEC performed, the Task Force endorses holding individuals performing HCEC accountable to the standards outlined in this report.” ASBH CC,2nd ed. p51

19. Terminology • Competency- An expected level of performance that integrates knowledge, skills, abilities and judgment. • Credentialing – A local, institutionally based review process to determine if an individual is qualified for a particular role (training, knowledge and skills). • Certification– Formal recognition that an individual satisfies established competency standards. • Accreditation – Formal recognition that an educational program or institution satisfies established standards for educating and training individuals to master a set of competencies.

20. Healthcare Ethics Consultation The general goal of HCEC is to improve the quality of health care through the identification, analysis, and resolution of ethical questions or concerns. Intermediate goals : • Identify and analyze the nature of the value uncertainty or conflict that underlies the consultation • Facilitate resolution of conflicts in a respectful atmosphere with attention to the interest, rights, and responsibilities of all those involved. ASBH CC(2011)

21. Emerging Process Standards Systematic Process Comprehensive policy Structure, organization & scope of service Process for consultation Access to consultation Known & available to patients/families/staff Hours of access & turn-around time 3. Notification of case consultation 4. Adequate documentation 5. Evaluation, quality review and process improvement.

22. Ethics Facilitation Model • Fair, inclusive, and transparent discussion • Informed by the context of the EC • Two core features: • Identify and analyze nature of value uncertainty • Facilitate the building of a principled ethical resolution

23. Broad Content Domains • Professionalism in patient care • Patient privacy and confidentiality • Shared decision making with patients • Ethical practices in end-of-life care • Ethical practices at beginning of life • Ethical practices in resource allocation • Ethical practices in research • Integration of ethics across organization Core Competencies for Health Care Ethics Consultation (2011).

24. Core Skills & Knowledge for CEC, 2nd Ed.

25. HCEC Process Elements • Access • Thorough, systematic process • Comprehensive policy • Formal meetings • Notification of a case consultation • Adequate documentation • Evaluation, quality review and process improvement.

26. Core Competencies 2nd Ed. Recognize necessity of QI knowledge/skills

27. Consultation & Advisement • Proactively identifying practices, structures, and policies that could be altered in order to improve patient care, avoid ethical conflicts, or better promote the mission and values of the organization. • Attention to ethical dimensions of everyday activities and decisions

28. Basic Competencies of HCEC • Knowledge of ERDs • Moral reasoning, ethical theory & key ethical principles • Ability to evaluate and weigh competing moral claims and values • Mediation skills; pastoral and facilitation skills • Familiarity with quality improvement process

29. Questions • Where is the evidence that a written exam is necessary to improve clinical ethics consultation? • Can we standardize a written exam for specific competencies when there is no single model of consultation?

30. Measurement of Skills and Knowledge • Written examination* • Observation of actual or simulated consultations* • Evidence of having performed a minimum number of consultations as “lead consultant” • Graduate degree in applicant’s field • Evidence of CEC education and training • Letters of reference from supervisor and a colleague who has provided CEC and observed applicant providing CEC* • Portfolio with summaries of consultations* • Panel interview* * to evaluate advanced CEC competencies through a certification process ASBH 2013

31. ASBH Required Elements for CEC Quality Attestation Portfolio Educational qualifications: Candidates are expected to have at least a master’s degree in a relevant discipline. Candidates without a master’s degree but with significant CEC experience must provide additional evidence of their qualifications for consideration. Portfolios should include the following: • curriculum vitae or resume • copies of diplomas or comparable documents • summary of candidate’s education and training related to ethics consultation • summary of CEC experience, with time frames and settings • summary of candidate’s philosophy of CEC, in 500 words or less • three letters of evaluation from individuals with responsibility for clinical oversight who are knowledgeable about the candidate’s ethics consultation activities • six case discussions of consultations in which candidate acted as lead or co-lead and authored or co-authored documentation, with discussions that demonstrate CEC practice in a variety of clinical settings • six one-page descriptions of additional cases that evidence CEC experience in a wide range of clinical settings and/or with a wide range of ethical issues.

32. Program Accreditation • Limited consensus on accreditation standards • Written exam cannot assess interpersonal skills • American Board of Program Directors developing plans for training program accreditation.

33. Moving Toward Professionalization • 1995 Joint Commission standard for “a mechanism for resolving ethical dilemmas” • ASBH Core Competencies for Health Care Ethics Consultation published in 1998. • Task force report on state of ethics consultation 2010. • ASBH Core Competencies 2nd edition 2011 • ASBH “Quality Attestation” project for expert level clinical ethics consultants 2013. • ASBH and Association of Bioethics Program Directors (ABPD) working together to assess individual skills and knowledge and accreditation process for clinical ethics training programs. • ASBH Code of Ethics, 2014. • CHA Striving for Excellence in Ethics (2014), 2nd ed.

34. Code of Ethics and Professional Responsibilities for HCECs American Society for Bioethics + Humanities, 2014 1. Be competent • Practice in a manner consistent with professional standards 2. Preserve integrity • Act with integrity in the performance of their role as consultant 3. Manage conflicts of interest and obligation • Anticipate and identify conflicts of interest and obligation and manage them appropriately 4. Respect privacy and maintain confidentiality • Protect private information obtained during HCEC, handling such information in accordance with standards of ethics, law, organizational policy 5. Contribute to the field • Consultants should participate in the advancement of HCEC 6. Communicate responsibly • Communicate in a manner consistent with the norms and obligations of the profession; clarify whether acting in HCEC role or as private citizen 7. Promote just health care within HCEC • Consultants should work with other professions to reduce disparities, discrimination, an inequities when providing consultations.

35. On the road to professionalization… Self-education Build Infrastruture CHA Assessment Tools Engage in QI Secure adequate resources ASBH Core Competencies

36. Doing Justice to Ethics • Community of reflection • Consensus on fundamental value priorities • Engaging in a logical, systematic, critical, consistent, and adequate method • Reflection that is adequate to the complexity of the concern addressed.

37. Mission “Remaining true to its mission is an ever increasing challenge for Catholic health care…What is at stake for Catholic health care is its remaining true to who it is and claims to be, and ensuring that who it is and what it does are closely aligned.” CHA, Striving for Excellence in Ethics(2014), p 6