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BY: JOHN J. MITCHELL, PhD

An Evaluation, Planning, and Outcomes Measures Process to Demonstrate Value

In 1999 the Institute for Ethics, a division of the Catholic HealthCare Partnership of New Jersey, launched a program to assist institutional ethics committees in several Catholic hospitals in northern New Jersey to evaluate the effectiveness of their institutional ethics committees, to provide a planning process for the ongoing work of the committees, and to assist in developing appropriate outcomes measures so the committees may more systematically and vigorously assess their effectiveness within their respective institutions.

Evaluation, Planning, and Outcomes Measures
The evolving role of institutional ethics committees imposes a responsibility on committee members to engage in a more vigorous evaluation of their work and the contributions they make within their health care organizations.^1,2 Two reasons demand this increased accountability. First, in today’s health care environment, greater accountability is rightfully being imposed on all aspects of the health care delivery system. Institutional ethics committees should not see themselves as exempt from a similar responsibility.^3,4 Second, to the extent that institutional ethics committees seek to enhance their authority within health care organizations, committee members should be able to demonstrate the value of the committee to their professional colleagues, their institutions, and the public. If the promotion of ethical awareness and behavior is an important value within health care organizations, institutional ethics committees should be able to provide evidence of this value.

Institutional ethics committee members also have an obligation to engage in a systematic planning process in which the members of the committee develop a consensus about those issues, tasks, and challenges requiring the attention of the committee. Failing to engage in a planning process may result in the committee’s agenda being driven more by the latest ethics "crisis" within the organization than by a coherent plan reflecting the ethics concerns that should take priority. The planning process need not be an elaborate or time-consuming affair, but it should challenge committee members and others in the organization with an interest in the work of the institutional ethics committee to articulate clearly their aspirations for the coming year and develop a plan to actualize those aspirations.

Institutional ethics committees have played an increasingly important role within health care organizations since their emergence 25 years ago.⁵ Traditionally, the core mission of institutional ethics committees has been to provide ethics education programs, develop appropriate ethics policies within the organization, and assist other health care professionals in the case consultation process. As the health care delivery system in the United States evolves and becomes increasingly complex, the role of the committees will and should expand beyond current core responsibilities. The maturation of the institutional ethics committee demands a greater degree of accountability within the health care organization. Simply put, if institutional ethics committees wish to play a role within the culture of health care organizations and assume a greater degree of responsibility, they must have a corresponding responsibility to demonstrate the contributions they make to improve the well-being of patients, health care professionals, and the organization’s ethical culture.⁶

In recent years health care professionals and institutions involved in all aspects of the delivery of patient care have been held to an increasingly greater responsibility to demonstrate the outcomes of the services that they provide. Although few believe that every aspect of patient care and the delivery of health care can be reduced to outcomes measures, the current environment within health care demands that health care professionals be able to demonstrate that they have achieved the intended objectives of the services delivered. Institutional ethics committees should be able to demonstrate the effectiveness of the services they provide within the organization.⁷

The Evaluation Process
The Institute for Ethics has developed an instrument to assist the institutional ethics committee members in several Catholic hospitals to assess the effectiveness of their committees to date. The evaluation instrument asks the committee members to:

• Identify three perceived strengths of the committee.
• Identify three significant accomplishments of the committee with the past year.
• Identify three perceived weaknesses of the committee and suggest appropriate remedies to overcome these weaknesses.
• Identify the most difficult issues addressed on a regular basis.
• Identify some of the new ethics issues that the committee will need to address in the future.
• Identify how the administration of the institution can provide additional assistance to the committee.

In the evaluation process designed by the Institute for Ethics, the committee members participating in the program were asked to complete the evaluation instrument individually. The staff of the Institute for Ethics compiled the results of the evaluations and shared them with the members of the respective committees. The subsequent discussions were informative and often vigorous. Identifying areas of diverging opinions, for example, about the strengths and weaknesses of the respective committees provided an opportunity for an enlightening discussion; eventually the committee developed consensus, identifying the most significant strengths and weaknesses. When the evaluation process was completed, the staff of the Institute for Ethics worked with the members of the respective committees to develop a list of priority concerns.

The Institute for Ethics is also currently working with the institutional ethics committees of several institutions belonging to a large Catholic health care system. The evaluation process has two goals. It is structured to identify the effectiveness of the committees of the individual institutions and provide a profile so that the administrative leadership can better understand how they might enhance the ethics agenda within the system. In this instance, the evaluation process may result in the creation of a system-wide ethics committee to provide assistance to the individual committees of the system’s member institutions.

The following represents a sampling of the results of the evaluation process of some of the committees to date. These examples are offered to provide a flavor of some of the issues and concerns that were identified.

Strengths and Accomplishments Committees are perceived to have been effective in empowering patients and family members confronting difficult ethical issues, especially end-of-life issues, the development of institutional ethics policies, and the sponsorship of ethics educational programs. The strength of many committees lay in their interdisciplinary composition and the spirit of cooperation among the members. Evaluations often mentioned that the committee provides an easily accessible forum for health care professionals to raise a variety of ethical concerns and problems involving patient care.

Weaknesses and Failures Participants frequently mentioned that their committees had failed to address adequately the ethical issues surrounding the allocation of health care resources. They also noted that the provision of end-of-life care is often perceived as futile, that is, offering little or no benefit to the patient. Members also recognized that committees have failed to address adequately a variety of organizational ethics issues or to grapple with a variety of ethical issues pertaining to the care of the poor and the uninsured. A number of participants also mentioned that the work of the committees was sometimes undermined because of a lack of administrative support.

Traditional and New Ethical Issues Several issues were identified that will continue to absorb the attention of institutional ethics committee members. These included the educational, policy development, and case consultation roles of the committee. End-of-life care issues will continue to be important concerns, especially pain management and palliative care for the terminally ill. Institutional ethics committees must maintain their interdisciplinary composition with an emphasis on the need to enhance the cultural, ethnic, and racial diversity of the committees. With respect to new challenges, institutional ethics committees will need to become more attentive to the ethical issues that arise "outside the walls" of the institutions inasmuch as health care organizations are providing more care outside the institution, such as in clinics and patients’ homes. Committees will need to address organizational ethics issues, especially those that have a direct impact on the quality of patient care.⁸ Finally, many participants in the evaluation process thought it would be important for future committees to embrace a greater advocacy role regarding public policy and its impact on the ethical dimension of patient care.

Planning and Outcomes Measures

Planning An annual planning process for institutional ethics committees does not need to be elaborate or time-consuming, but it should challenge the members of the committee, and others in the organization committed to the work of the committee, to articulate clearly their goals and objectives for the coming year and how they intend to realize them. The Institute for Ethics has developed a planning instrument for this purpose. It asks all the participants in the planning process to complete the instrument individually. A meeting is then held to prioritize the objectives identified. The planning instrument asks that the following be identified:

• Goals
• A program to realize each of the goals
• Accountability for each program (who will assume responsibility)
• A timetable for each program (defined in stages)
• The outcome expected
• A method for assessing the success of each program

The planning process could contain more than these six elements, but at the outset of a committee’s effort to engage in systematic planning, six seem sufficient to challenge the committee members to develop a rational planning process.

In the planning work that the staff of the Institute for Ethics has done with several institutional ethics committees, we have learned that it is important to spend time with the entire committee to decide on the two or three goals and programs for the next 12 months. Choosing too many goals will likely lead to frustration. Individual members of the committee or a group of members must assume responsibility for a specific program; otherwise, follow through is more difficult to achieve. Finally, each program must have a specific outcomes measure that can be the basis for measuring the success of that particular program. For example, if the goal is to improve the quality of pain management to patients within the organization, and the specific program is clinician education, every effort must be made to benchmark the knowledge of clinicians before the initiation of the education programs. An equally vigorous effort must be made to assess learning at the end of the process. The committee should identify the learning curve increase expected and measure knowledge improvement against that goal.

Outcomes Measures As the health care system in the United States becomes increasingly complex, the role of institutional ethics committees will expand beyond their core responsibilities of education, policy development, and case consultation. Evidence of an anticipated further maturation of institutional ethics committees is suggested by the fact that the Joint Commission for the Accreditation of Healthcare Organizations is not only increasingly interested in the work of the committees, but also has suggested a role for the committees regarding organizational ethics issues, especially those that have a direct link to the quality of patient care.^9-11 Maturation of institutional ethics committees requires a greater degree of accountability within the organization, which requires a corresponding responsibility to demonstrate the contributions they make to patient welfare and the service they provide to health care professionals and the organization. Furthermore, as members of the general public become more knowledgeable (and perhaps more cynical) about the health care system, they will likely become more interested in knowing and understanding the work of institutional ethics committees, which bear special responsibility for nurturing the ethical dimensions of health care delivery.

Some relatively simple examples are available to demonstrate how institutional ethics committees can be held to outcomes measures. These examples go to the core of the traditional mission of committees as well as some expanded responsibilities. If the committee, or some of its members, regularly engage in the case consultation process, a mechanism should be in place to assess what outcomes were achieved as a result of the consultation that would not have occurred had the consultation not taken place. To the extent that the committee plays an important role in the development of institutional policies, which affect the well-being of patients and/or health care professionals, what is the evidence of the effectiveness of these policies, and how is this effectiveness measured? If the committee makes a decision to extend its mandate "outside the walls" of the organization to provide services to a variety of outpatient services, how will the committee measure the effectiveness of these new ventures?¹² If the committee chooses to assume an advocacy role relative to public policy issues with links to patient care and well-being, how will the effectiveness of these new efforts be measured? Even though the development of an outcomes measures process may be new to the work of institutional ethics committees, committee members should be confident that by entering into this process they can improve and, more importantly, demonstrate the contributions they make to their institutions.

A New Rigor
The development and implementation of an evaluation, planning, and outcomes measures process for institutional ethics committees is a work in progress. This process introduces a new rigor into the way committee members think about their responsibilities and their obligation to be more accountable in their work to their colleagues and their institutions. Two certain benefits of the project are already apparent. First, committee members are challenged to develop an increased sense of the professionalism expected of them, consequently enhancing their sense of the importance of institutional ethics committees in their organizations.^13,14 Second, an opportunity to expand the ethical imaginations of committee members is provided. For a long time institutional ethics committee members have typically functioned within the fairly circumspect world defined by their institutional boundaries and the traditional tasks of education, policy development, and case consultation. But times are changing, especially in health care. The evaluation, planning, and outcomes measures process challenges committee members to think "outside the walls" of their institutions as well as their current imagination about the responsibilities of their committees.

An interesting by-product of the current project is that it has brought to the surface a variety of new challenges for committee members. Some of these ideas have already been mentioned. As a result of the evaluation and planning process, committees are raising issues related to organizational ethics and the linkage of some of these issues to a traditional ethics committee agenda. Some have talked about the need to carry a committee’s agenda into the public arena through public advocacy for the needs of the poor and the underinsured. Other committees have recognized the need to stretch their imaginations and focus on the ethical issues that are emerging as a consequence of the increasing delivery of health care outside the traditional institutional setting.

The work of institutional ethics committees will continue into the future. One mark of their continuing role within health care organizations should be their increasing professionalism, which can be furthered by a commitment to an ongoing evaluation, planning, and outcomes measures process.

Dr. Mitchell is chairperson, Department of Biomedical Ethics, School of Graduate Medical Education, Seton Hall University, South Orange, NJ. He is also director, Institute for Ethics, a division of the Catholic HealthCare Partnership of New Jersey.

Notes

1. Sigrid Fry-Revere, "Some Suggestions for Holding Bioethics Committees and Consultants Accountable," Cambridge Quarterly of Healthcare Ethics, vol. 2, no. 4, Fall 1993, pp. 449-455.

2. Sigrid Fry-Revere, The Accountability of Bioethics Committees and Consultants, University Publishing Group, Frederick, MD, 1992.

3. Linda S. Scheirton, "Determinants of Hospital Ethics Committee Success," H.E.C. Forum, vol. 4, no. 6, 1992, pp. 342-359.

4. Glenn G. Griener, et al. "Hospital Ethics Committees: Problems in Evaluation," H.E.C. Forum, vol. 4. no. 4, 1992, pp. 5-18.

5. Karen W. Teel, "From Quinlan to Today," Cambridge Quarterly of Healthcare Ethics, vol. 1, no. 4, Fall 1992, pp. 291-294.

6. Stanley Joel Reiser, "The Ethical Life of Health Care Organizations," Hastings Center Report, Nov.-Dec. 1994, pp. 28-35.

7. Robin Fretwell Wilson, "HECs: Are They Evaluating Their Performance?" H.E.C. Forum, vol. 5, no. 1, 1993, pp. 1-34.

8. Robert Lyman Porter, "From Clinical Ethics to Organizational Ethics: The Second Stage of the Evolution of Bioethics," Bioethics Forum, Summer 1996, pp. 3-12.

9. Leonard J. Weber, "Taking on Organizational Ethics," Health Progress, May-June 1997, pp. 20-23, 32.

10. Ron Hamel, "A Question of Value," Health Progress, May-June 1997, pp. 24-26,32.

11. Elizabeth Whitley, et al. "A Corporate Approach to Healthcare Ethics," H.E.C. Forum, vol. 7, no. 5, 1993, pp. 296-301.

12. Robert Moss, "Ethics Committees Across a Continuum of Care," H.E.C. Forum, vol. 7, no. 4, 1995, pp. 243-251.

13. Bernard Lo, "Promises and Pitfalls of Ethics Committees," New England Journal of Medicine, vol. 317, no. 1, 1987, pp. 46-49.

14. David C. Blake, "The Hospital Ethics Committee: Health Care’s Moral Conscience or White Elephant?" Hastings Center Report, Jan.-Feb. 1992, pp. 6-11.