e-Ethics JULY 2002
Institutional Ethics Committees: A New Vision
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Despite ethics committees'
undoubted success in addressing
ethical problems in health care, the
first flush of enthusiasm generated
by progress in such areas as forgoing
treatment, do-not-resuscitate
policies, and patient self-determination
has passed. Many ethics committees
across the country have
become little more than discussion
groups—their meetings often providing
enjoyable occasions to "feel
good" about committee activities,
but also interspersed with long periods
of "dead time." In a healthcare
environment concerned with
patients' rights and organizational
ethics, however, new challenges
have arisen. These provide ethics
committees with opportunities to
regroup and re-imagine themselves.
Recent literature on clinical and
organizational ethics has suggested
a number of ways to revitalize
ethics committees. The following
ideas are intended to serve as possibilities,
not a prescription.
Committee responsibilities
To integrate an ethics committee
more fully into the healthcare institution's
organizational life, the institution's
leaders need to reimagine
the committee's organizational alignments
and responsibilities. For
example, the vice president for operations
could assume responsibility
for the existence and effectiveness
of the ethics committee. It would
report its activities not only to the
vice president, but ultimately to the
institution's chief executive. The vice
president for operations would
ensure that the ethics committee
chair has sufficient support to fulfill
the committee's responsibilities. The
vice president might, among other
things, assign clerical and administrative
staff to support the chair in
conducting ethics committee business,
and might also ensure that the
chair is released from other responsibilities
to permit effective service
as committee chair.
In this organizational structure,
ethics committee members would
receive the same privileges and support
as members of other administrative
committees. No longer would
members feel that they were "donating"
or "volunteering" their time;
instead, they would know that they
were involved in an ongoing effort,
institutionally recognized and supported,
to effect change within the
organization.
Budget responsibilities
Since money talks, one way to
promote parity with other institutional
committees is to fund the ethics
committee at the level that its annual
goals and objectives, and previous
budget reports, indicate. Its chair
would have the same authority as
other budget managers to determine
committee-related spending. The
budget would fund such items as the
agreed-upon educational needs of
committee members and the committee's
mission-related research
and improvement projects.
Committee structure and
selection criteria
In the new vision, the identity
and mix of committee membership
would change. Traditionally, an ethics
committee's membership has represented
multiple disciplines and perspectives
in order to ensure the
broadest possible consideration of
issues. This model would continue,
but the chair (especially) would possess
demonstrated organizational
and management skills and an ability
to handle group dynamics. In
addition to other specified individuals,
ethics committee membership
would include (1) senior and mid-level
administrative staff, (2) senior
nursing staff, (3) members of other
clinical and support services, and (4)
formally appointed representatives
of the medical staff. The medical staff
would appoint physicians representing
(1) the medical staff executive
committee (or its equivalent), (2) the
medicine and surgery committees
(or their equivalent), and (3) the primary
care or family practice commit-tee
(or its equivalent). While no specific
limits on membership need be
set, it may be advisable for the committee
to be relatively small, supplemented
by "working groups" of individuals
temporarily assigned to or
enlisted by the committee to serve
on specific projects or standing subcommittees
(such as a case consultation
team or the development of policy
and procedures).
Operational policies and methods
of operation
The committee would revise and
regularly update its operational policies
and protocols, and would develop
an annual plan outlining its
goals, strategic objectives, and
action plans. It would develop procedures
for carrying out the following
committee responsibilities:
Selecting and establishing priorities,
projects, and tasks, and issues for
which the committee will develop practice
improvement interventions;
Implementing the practice improvement
interventions;
Monitoring the effects of these interventions;
and
Evaluating the interventions' effectiveness
and/or significance for organizational
culture and patient care.
To accomplish these responsibilities,
the committee may choose to adapt the
frameworks, methodologies, and techniques
of system quality improvement
(SQI), continuous quality improvement
(CQI), and other healthcare quality or
organizational improvement approaches.
Relationships with other committees
and administrative offices
Members of the ethics committee
would work closely with quality review,
risk management, nursing administration,
the medical staff executive committee,
and the Institutional Review
Board (if applicable). These relationships
might take the form of regularly scheduled
joint meetings; representation of
the other committee on the ethics committee,
and/or vice versa; representation
of the administrative office on the ethics
committee and/or of the ethics committee
in management meetings of the
administrative office; regularly scheduled
reports on the ethics committee's
activities and projects to the other committee
or administrative office; or any
other means that ensure a regular, well-defined
working relationship so that the
concerns and efforts of each committee
or office would be represented in its
counterpart.
Committee assessment and evaluation
Continuing assessment and evaluation
of the ethics committee's operations
and outcomes would be an expectation.
For example, periodic self-assessment of
its meetings would help the committee
monitor its work. The committee's projects
and sponsored activities would
undergo an assessment at regular intervals
and upon completion. An annual
evaluation of the committee's overall
effectiveness would be conducted, and
the results reported through the vice
president for operations to the institution's
chief executive. The senior leaders
could then respond to the evaluation with
recommendations for new operational
practices or new committee projects.
While a number of these ideas are
still being debated, efforts to reimagine
the purpose and function of ethics committees
are under way in healthcare
institutions and systems around the
country. As ethics committees expand
their scope from the traditional focus on
clinical ethics to include questions of
organizational ethics, they will need to
approach their work in fresh and creative
ways. A re-imagined ethics com-mittee,
more closely integrated into the
organizational structure of its institution
and intent on realizing the organization's
values, will do much to enhance associate
and patient satisfaction.
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