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Ethics and Quality:
Improvement and Impact.
SJHS – The Ministry
Humboldt County
Sonoma County
Napa County
High Desert
Orange County
Eastern New Mexico
West Texas
Serve communities in 3 States through 14 Hospitals, 3 Integrated Medical Groups, Home Health and Outreach Market Share Leader in Every Region
SJHS Next Generation PracticesThe Need for Innovation
Ethics committee members were having common complaints:
• Feeling like we were putting out the same “fires”.• Tired of sitting and listening to “ethics gossip”.• The focus on education: “to educate and hope is a
futile strategy”.• A “culture” to meet, review, debate, and perhaps
advise.• Is it the best model to address evolving demands and
build our ethics capacity? (25 people meeting once a month?)
• Impact: The desire to execute and measure our work.
SJHS Next Generation Practices
10 Years in Review
1. Practices in Ethics Innovation: “Tests of Change”
2. Practices in Diffusion: “Having Impact Spread”
SJHS Next Generation PracticesPractices in Ethics
Innovation
SJHS Next Generation PracticesSJHS “Principled
Innovation”The four principles which frame the orientation of our ethics services are:
1. To be proactive and not just reactive.2. To be organizationally integrated and not
isolated.3. To be held accountable for performance
based on demonstrable outcomes and not simply good intentions.
4. To be oriented by and rooted in SJHS core values and not merely external legal, regulatory, or accreditation requirements.
SJHS Next Generation Practices
Next Generation Structure
• Dual Roles of CEAT and SEG
• Ethics ACEs Program• Executive Ethics
Liaisons
SJHS Next Generation PracticesInnovation, Integration and
“Standard Work”• Ready Reference Grid• Flowchart for Resolving Ethics Issues• Ethics at a Glance Manual• Ethics Moments• Performance Measures for Roles (What does success look
like?)• Green Belt training for Ethics Leaders.• Use of Adverse Event Software (Peminic) for tracking and
notification.• Ethics Component of Internal Audit.• Utilizing electronic consult databases to track history, gain
trending data, and provide more consistent assessments.• Currently exploring ethics leader’s activities integrated into
yearly performance review by local leader. • Using Stratana software to create Ethics Dashboard.
The Difference betweenThe Difference betweenResearch and ImprovementResearch and Improvement
RESEARCH: Purpose is to
discover new knowledge
Focus on one large “blind” test
Try to control for biases
Gather as much data as possible--“just in case”
Can take a long time to obtain results.
IMPROVEMENT: Purpose is to bring
new knowledge into daily practice.
Many sequential observable tests
Stabilize the biases from test to test
Gather enough data to learn and complete another cycle
Small tests of significant changes accelerate the rate of improvement.
SJHS Next Generation PracticesAIM: Replicating Proven Ethics/Quality Initiatives
An early, ethics intervention in ICU, addressing patients on the ventilator for 96 continuous hours (some of the most challenging in ICU), in order to improve team communication and decision making in accord with patient preferences.
Mel Dowdy, et al, “At Study of Proactive Ethics Consultation for Critically and Terminally
Ill Patients with Extended Lengths of Stay.” Critical Care Medicine. 1998, Vol 26., No 2.
SJHS Next Generation Practices Intervention
• First: At 96 hours on ventilator, patient chart reviewed regarding advance directive, decision making competency, family and clinical team awareness of treatment plan, hurdles to recovery, limits to treatment or identification of other unaddressed issues.
• Second: Gaps regarding communication and orders are identified. Attending physician, bedside nurse and nurse manager are made aware of gaps in order to have them addressed.
• Third: Gaps are addressed and documented in the chart.
SJHS Next Generation PracticesMeasures: How will we know that the intervention is an
improvement? • Retrospective: 30 charts reviewed of ICU patients on continuous ventilation for 96 hours previous to “go live” date (March 1, 2006) using 96 Hours Chart Observational Tool.
• Increase in early documented interdisciplinary communication on ethically difficult treatment decisions and care plans at 2, 4, 6 days after intervention using Quality Communication Index. (Variable, individual and moving range chart)
• Increase in documented decisions/orders regarding DNR, withholding or withdrawing, or other life sustaining decisions at 2, 4, 6 days after intervention.
SJHS Next Generation PracticesTwo Groups Will Be Compared
– A retrospective baseline group. Three months of patients on 96 hrs of continuous ventilation in ICU reviewed with three measures in mind.
– An intervention group where the early ethics intervention occurs after the patient had received 96hrs of continuous mechanical ventilation.
SJHS Next Generation Practices
Impact• At St. Joseph: Full DNR orders almost doubled and other
indicators went down because early conversations caused aggressive care plans not to begin.
• At St. Jude: Greater awareness of advance directives and doubling of orders to withhold and withdraw treatment.
• At Queen of the Valley: Challenged with small number of patients meeting 96 hour criteria.
SJHS Next Generation Practices
Local Ministry Initiatives
1. Completion of Advance Directives before entering hospital.
2. In-hospital DNR.3. Pre-hospital EMS DNR Form
completed for Home health patients.
4. Increase Length of Stay in Hospice.5. Blood Products and Jehovah
Witness Community.
SJHS Next Generation Practices
A3 Tool
1. Reason for Action.
2. Initial State3. Target State4. Gap Analysis5. Insights
6. Solution Approach
7. Rapid Experiments
8. Completion Plan
9. Confirmed State
Many causes
Water Filled Hull
Ship Couldn't
Turn Quickly Enough
Ship Hit Iceberg
Atlantic Crossing
Ship in Water
Ship in Water
Speed (18 knots)
Size of Rudder
Saw iceberg late
AND AND
AND
AND
AND
Strength of Steel
Titanic Sank
Water Filled Hull
Iceberg Present
Steel Plates Buckled on
Hull
Opening in Hull
Ship Couldn't Turn Quickly
Enough
Titanic Sank
Ship Hit Iceberg
Atlantic Crossing
Ship in Water
Ship in WaterBusiness of Company
Speed (18 knots)
Size of Rudder
Record attempt
Saw iceberg late
No Binoculars
Strength of Steel
North Atlantic
ANDAND
AND
AND
AND
AND
Strength of Steel
Titanic Sank
Cause Map Tool
SJHS Next Generation Practices
What We Are Learning• People: Attracting a different type of ethics participant.
Connecting System improvements to individual stories.
• Developing Change Agents: Not simply developing people regarding ethics analysis but how to manage a change initiative.
• New Network of “Partners”: Some silos were dismantled (Risk), some were discovered anew (Integrated Performance Review).
• Measurement: Developing a safe and accountable environment as opposed to a threatening one.
• Persistence: Many systemic ethics issues have deep cultural roots and require sustained efforts.
SJHS Next Generation Practices
Practices of Diffusion
Characteristics of People Adopting Change
2.5%
Early Adopters
“The Watched”
13.5%
EarlyMajority
Require Local Personal Trust
34%
Late Majority
“Standard of Practice”
34%
Traditionalists“Tried and True”
16%
Innovators
From Diffusion of Innovations by Everett Rogers:
SJHS Next Generation PracticesInfluential Factors for Spreading
Change
1.Perceived benefit of change. 2.Compatible with current needs,
belief systems and processes3.Simplicity of proposed
intervention4.Trial ability5.Observability.
SJHS Next Generation PracticesThe “To Do” List for Ethics
Leaders1. Find sound innovations. 2. Find and support Innovators.3. Invest in Early Adopters.4. Make early adopter activity
observable.5. Trust and enable reinvention.6. Create slack for change.7. Lead by example.
SJHS Next Generation PracticesMake Early Adopter Activity
Observable1) Monthly Conference Calls: A3
Presentation/Innovation Discussion2) Peer Learning Among Local
Ministries3) Electronic Networking: Sharing Our
Measured Work on Website.4) Annual Ethics Leaders Workshop 5) Local Ministry Ethics Dashboard.
SJHS Next Generation PracticesWhat We Are Learning…
• Ethics Initiatives are like “World Peace”: We focus on “small tests of change” and improvement.
• Communication: How do we communicate well locally and system wide the ethics work being accomplished?
• Sustaining Results: There is not clarity on when an EPIP or a workplan goal is “done”. How does hand-off for monitoring occur?
• Standard Work: We record goals and data differently. What kind of standardization and comparison makes sense given unique local ministries?