Preventive EthicsBeyond the Basics

Module 1Determining Whether an Issue Is Right for the ISSUES Approach

Learning Objectives

• Describe the criteria for determining whether an issue is appropriate for a quality improvement approach such as ISSUES.

• Apply the criteria to determine whether an issue is appropriate for a quality improvement approach such as ISSUES.

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ISSUES Link

IDENTIFY an Issue

Be proactive in identifying ethics issues

Characterize each issue

Clarify each issue by listing the improvement goal

Prioritize the issues and select one

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Appropriateness for PE

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Appropriateness for PE

1 2 3 4 5 6 7 8 9 10 11 12 13

Date Issue Came toAttention of PE (mm/dd/yy)

Source of Issue (1–2 words)

Possible Ethics Issue (who, what, where, when, how much

or how often)

Immediate Action Req’d (Y/N)

Simple Problem/Obvious Solution (Y/N)

Other Program Responsible for This Issue (Y/N)

Ethics Quality Gap

Preliminary Improvement Goal

Appropriate for PE (Y/N)

Best Ethics Practice

Current Ethics

Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

    .          

                 

                 

                 

Selecting Issues for a QI Approach

A quality improvement approach is appropriate for issues resulting from failures caused by systems or processes that may not be reliably producing the desired outcome.

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Selecting Issues for a QI Approach: Another Consideration

• Appropriate for issues that require further study to accurately describe current workflow process, ethics quality gap, underlying causes of gap

• Small-scale testing also needed

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Tools for Assessing Appropriateness

• Choosing Issues for PE—Worksheet

• Choosing Issues for PE: Tracking Tool

• IntegratedEthics Health Care Ethics Domains and Topics

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Appropriateness for PE

1 2 3 4 5 6 7 8 9 10 11 12 13

Date Issue Came toAttention of PE (mm/dd/yy)

Source of Issue (1–2 words)

Possible Ethics Issue

(who, what, where, when, how much

or how often)

Immediate Action Req’d (Y/N)

Simple Problem/Obvious Solution (Y/N)

Other Program Responsible for This Issue (Y/N)

Ethics Quality Gap

Preliminary Improveme

nt Goal

Appropriate for PE (Y/N)

Best Ethics Practice

Current Ethics

Practice

Ethics Domain

Ethics Topic

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Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

    .          

                 

Urgent Issue?

Does the issue require urgent and immediate action by leadership?

Take to leadership!!

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4 5 6

Immediate Action Req’d (Y/N)

Simple Problem/Obvious Solution (Y/N)

Other Program Responsible for This Issue (Y/N)

Simple Issue?

Is the issue simple, with an obvious solution?

Just do it!

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4 5 6

Immediate Action Req’d (Y/N)

Simple Problem/Obvious Solution (Y/N)

Other Program Responsible for This Issue (Y/N)

Another Program Responsible?

Is there another program or service responsible for this issue?

Refer or collaborate

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CAUTION

4 5 6

Immediate Action Req’d (Y/N)

Simple Problem/Obvious Solution (Y/N)

Other Program Responsible for This Issue (Y/N)

Ethics Quality Gap

The disparity between what should be (best ethics practice) and what is (current ethics practice)

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7 8 9 10 11

Ethics Quality Gap

Best Ethics Practice

Current Ethics

Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

       

Best Ethics Practice

• Ethics domain• Ethics topic• Ethical standard

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7 8 9 10 11

Ethics Quality Gap

Best Ethics PracticeCurrent Ethics

Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

       

Ethics Domain?

• Clinical • Business • Research

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7 8 9 10 11

Ethics Quality Gap

Best Ethics Practice

Current Ethics Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

       

Ethics Topic?

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7 8 9 10 11

Ethics Quality Gap

Best Ethics Practice

Current Ethics Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

       

• Written standards• Ethics expertise

Inconsistent with Ethical Standards, Norms, or Expectations?

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7 8 9 10 11

Ethics Quality Gap

Best Ethics Practice

Current Ethics Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

       

Current Ethics Practice

• Measurable data• Easily collected data

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7 8 9 10 11

Ethics Quality Gap

Best Ethics Practice

Current Ethics Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

       

• Measure ethical practice • Express as percent or number

Measurable Data Available?

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7 8 9 10 11

Ethics Quality Gap

Best Ethics Practice

Current Ethics Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

       

• Consider data collection method required for easily collecting the data

Easily Collected Data?

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7 8 9 10 11

Ethics Quality Gap

Best Ethics Practice

Current Ethics Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

       

Example: Advance Directives Issue

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.

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Ethics Domain?

Column 7: Is there an ethics domain related to this issue?

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.

Shared Decision Making with Patients

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Ethics Topic?

Column 8: Is there an ethics topic related to this issue?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.

Advance Care Planning

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Standards, Norms, or Expectations?

Column 9: Is the practice inconsistent with ethical standards, norms, or expectations?

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 1004.02 Advance Care Planning and Management of Advance Directives

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Quantifiable Data?

Column 10: Is quantifiable data about current ethics practice readily available?

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.

No

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Quantifiable Data?

Column 11: Is quantifiable data about current ethics practice easily collected?

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.

Yes, through several methods such as health record reviews or interviews of patients or staff

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Appropriate for ISSUES Approach?

Does this issue suggest an ethics quality gap amenable to an ISSUES approach?

YES!

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1 2 3 4 5 6 7 8 9 10 11

Date Issue Came toAttention of PE (mm/dd/yy)

Source of Issue (1–2 words)

Possible Ethics Issue

(who, what, where, when, how much

or how often)

Immediate Action Req’d (Y/N)

Simple Problem/Obvious Solution (Y/N)

Other Program Responsible for This Issue (Y/N)

Ethics Quality Gap

Best Ethics Practice

Current Ethics

Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

    .        

When Issue Isn’t Appropriate

• Get back to process owner for identified issue.• Explain reasoning for PE team’s decision.• Help program or service think through where else

they might turn for assistance.• Ask ethics program leadership to assist.

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• Draft general statement of the desired ethical practice

Preliminary Improvement Goal

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4 5 6 7 8 9 10 11 12

Immediate Action Req’d (Y/N)

Simple Problem/Obvious Solution (Y/N)

Other Program Responsible for This Issue (Y/N)

Ethics Quality Gap

Preliminary Improvement Goal

Best Ethics Practice

Current Ethics

Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

         

Tracking Tool:Advance Directives Issue

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Appropriateness for PE

1 2 3 4 5 6 7 8 9 10 11 12 13

Date Issue Came to Attention of PE (mm/dd/yy)

Source of Issue (1–2 words)

Possible Ethics Issue (who, what, where, when, how much

or how often)

Immediate Action Req’d (Y/N)

Simple Problem/Obvious Solution (Y/N)

Other Program Responsible for This Issue (Y/N)

Ethics Quality Gap

Preliminary Improvement Goal

Appropriate for PE (Y/N)

Best Ethics Practice

Current Ethics

Practice

Ethics Domain

Ethics Topic

Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N)

Data Available (Y/N)

If Data Unavailable, Easily Collected (Y/N)

9/15/XX

TJC

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.

N N N SDM ACP Y N Y

Increase assistance to primary care patients who request help with completing an advance directive

Y

Group Activity InstructionsHandouts 1.2, 1.3, 1.5–1.10 (20 min)

1. Answer questions 4–12 on worksheets.2. Mark answers on tracking tool (Handout 1.2).

Be prepared to discuss:• Is issue appropriate for PE, and why (or why not)?• If uncertain after applying criteria, what other

information might help you decide? • What will you do if it is not appropriate for ISSUES

approach?

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Takeaways

Determining whether an issue is right for the ISSUES approach• Being good stewards of your resources; excluding

issues that aren’t appropriate• Using appropriateness criteria on worksheet and

tracking tool• Looking for ethics quality gap • Drafting preliminary improvement goal

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Module 1

Questions?