Mary Beth Foglia

The Disclosure Dilemma — Large-Scale Adverse Events

Some adverse events such as a failure to disinfect medical equipment have the potential to harm many patients. The authors argue that medical institutions should develop policies for addressing large-scale adverse events and should routinely disclose these events to patients, even when the risk of harm is very low.

Ethics Consultation Quality Assessment Tool: A Novel Method for Assessing the Quality of Ethics Case Consultations Based on Written Records.

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool (ECQAT). ECQAT enables raters to assess the quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation (ethics question, consultation-specific information, ethical analysis, and conclusions and/or recommendations), established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT, the resulting product, and recommended future testing and potential uses for the tool.

Preventive Ethics: Addressing Ethics Quality Gaps on a Systems Level

BACKGROUND Preventive ethics (PE) is a key component of IntegratedEthics (IE), an innovative model developed by the Veterans Health Administration (VA)s National Center for Ethics in Health Care which establishes a comprehensive, systematic, integrated approach to ethics in health care organizations. Since early 2008, IE has been implemented throughout all 153 medical centers and 21 regional networks within the US Department of Veterans Affairs (VA) health care system. ISSUES A STEP-BY-STEP APPROACH TO ETHICS QUALITY IMPROVEMENT: PE employs a systematic, step-by-step process improvement approach called ISSUES Identify an issue, Study the issue, Select a strategy, Undertake a plan, Evaluate and adjust, and Sustain and spread. After the ethics quality gap is described, a measureable and achievable improvement goal based on the gap is developed. One of the most challenging aspects of describing an ethics quality gap is to establish an appropriate ethical standard on which to base the operational definition of best ethics practice. PRACTICAL STEPS TO DEVELOPING A PREVENTIVE ETHICS FUNCTION: Within the VAs IE model, PE is situated as a subcommittee of the IE council, which is chaired by the facility director (equivalent to a hospital chief executive officer) and oversees all aspects of the organizations ethics program, including ethical leadership, ethics consultation, and PE. Each VA medical center is required to have a PE team led and managed by a PE coordinator and may need to address ethics issues across the full range of health care ethics domains. CONCLUSIONS The VAs IE model establishes a robust conceptual framework, along with concrete tools and resources, to integrate PE concepts into the day-to-day operations of a health care organization and is directly transferrable to other health care organizations and systems.

Health Disparities among LGBT Older Adults and the Role of Nonconscious Bias

This paper describes the significance of key empirical findings from the recent and landmark study Caring and Aging with Pride: The National Health, Aging and Sexuality Study (with Karen I. Fredriksen-Goldsen as the principal investigator), on lesbian, gay, bisexual, and transgender aging and health disparities. We will illustrate these findings with select quotations from study participants and show how nonconscious bias (i.e., activation of negative stereotypes outside conscious awareness) in the clinical encounter and health care setting can threaten shared decision-making and perpetuate health disparities among LGBT older adults. We recognize that clinical ethicists are not immune from nonconscious bias but maintain that they are well situated to recognize bias and resulting injustice by virtue of their training. Further, we discuss how clinical ethicists can influence the organizations ethical culture and environment to improve the quality and acceptability of health care for LGBT older adults.

The IntegratedEthicsTM Staff Survey: A Tool to Evaluate and Improve Ethical Practices in Health Care

Background: To improve ethics quality in health care, health care organizations need a way to characterize whether ethical practices throughout the organization are consistent with accepted ethics standards, norms, and expectations for the organization and its staff. We developed the IntegratedEthics™ Staff Survey (IESS) to fill this need. Methods: The IESS was developed and validated through a rigorous multiyear process. This process included reviews of the bioethics and health care literature to develop conceptual maps of common ethical issues in health care; focus groups and interviews with institutional stakeholders to identify key ethical concerns; cognitive testing, pilot testing, and field testing to ensure that questions were understandable and useful; and item reduction and modification to reduce respondent burden. Results: The IESS addresses staff perceptions of ethical practices in nine domains: everyday workplace, business and management, government service, patient privacy and confidentiality, resource allocation, shared decision making with patients, professionalism in patient care, end-of-life care, and research. The 2010 version of the survey consisted of 76 questions (excluding 8 demographic questions), including questions about the degree to which facility staff demonstrate behavior consistent with specific ethical practices, systems-level or organizational factors that support or interfere with ethical practices, and the ethical environment and culture. The IESS has served as a catalyst for multiple quality improvement and educational activities. Conclusions: The IESS represents an across-the-board approach to measuring ethics quality in multiple areas encompassing clinical, organizational, and research ethics. In addition to its use in quality improvement efforts, the IESS may be used to assess whether there are systematic differences across different disciplines, services, and supervisory levels; to evaluate the effectiveness of ethics programs; and to identify trends in ethical practices over time.

Perceptions of Ethical Leadership and the Ethical Environment and Culture: IntegratedEthicsTM Staff Survey Data from the VA Health Care System

Background: To enhance understanding of ethical leadership and the ethical environment and culture (EL/EEC) in the Department of Veterans Affairs (VA) health care system, we mapped selected questions from the VA IntegratedEthics™ Staff Survey (IESS), a national survey of employees’ perceptions of ethical practices, to the Ethical Leadership Compass Points (ELC), a tool to help leaders cultivate an environment and culture that makes it easy for employees to “do the right thing.” The ELC distills insights and principles from organizational and business ethics and provides leaders with specific behaviors that can be incorporated into daily administrative routines. Methods: We analyzed the responses of 88,605 VA employees to the 2010 IESS questions that previously were mapped to the ELC. Descriptive statistics were used to characterize overall distribution of responses to the survey questions, and Pearsons chi-squared tests were performed to assess differences in responses by employee characteristics. Multiple regression analyses examined the association between perceptions of EL/EEC and perceptions of the organizations’ overall ethics quality. Results: Physicians and employees with a higher level of supervisory responsibility were more likely to have the most positive perceptions of EL/EEC and the organizations overall ethics quality. More than three-quarters of the variation in perceptions of overall ethics quality was explained by employee perceptions of EL/EEC. The IESS questions that showed the largest associations with perceptions of overall ethics quality addressed fair allocation of resources across programs and services, avoidance of mixed messages that create ethical uncertainty or conflict, fair treatment of employees, and following up on ethical concerns reported by employees. Conclusions: These results support the important relationships between ethical leadership, an organizations environment and culture, and overall ethics quality. Certain ethical leadership practices may have a larger impact on employees’ perceptions of overall ethics quality than others.

How Do Healthcare Employees Rate the Ethics of Their Organization? an Analysis Based on VA IntegratedEthics® Staff Survey Data

EXECUTIVE SUMMARY Healthcare organizations with an ethical culture experience higher levels of employee productivity, less staff turnover, better levels of patient safety, resource and cost savings, and higher levels of patient satisfaction. Employees’ perceptions of the ethics of their organization are considered a good indicator of the ethics culture. How employees rate the ethics of their organization is not well understood. Previous research has identified a number of attributes that are salient to employees’ perceptions in this area. However, little is known about how employees synthesize their perceptions of these attributes to rate the ethics of their organization. Without this knowledge, managers have little specific information to act on to improve practices that would in turn improve employees’ perceptions of their organization’s ethics. For this study, we used data from Department of Veterans Affairs’ (VA) 2014 IntegratedEthics® Staff Survey administered to Veterans Health Administration (VHA) staff. We used multivariate regression analyses to investigate how VHA employees weigh their perceptions of eight attributes of an ethical organization to inform an overall rating of the ethics of their organization. We found that employee perceptions of fairness, clarity of expectations, accountability, and leadership’s prioritization of ethics had the strongest associations with the overall rating. In addition, employees disproportionately weighed their positive perceptions in determining their overall rating. Therefore, a strategy to improve employees’ perceptions of these attributes could potentially have the greatest marginal return on investment with respect to improving employees’ perceptions of the ethics of an organization.

The Time Is Now: Bioethics and LGBT Issues

Our goal in producing this special issue is to encourage our colleagues to incorporate topics related to LGBT populations into bioethics curricula and scholarship. Bioethics has only rarely examined the ways in which law and medicine have defined, regulated, and often oppressed sexual minorities. This is an error on the part of bioethics. Medicine and law have served in the past as societys enforcement arm toward sexual minorities, in ways that robbed many people of their dignity. We feel that bioethics has an obligation to discuss that history and to help us as a society take responsibility for it. We can address only a small number of topics in this special issue of the Hastings Center Report, and we selected topics we believe will stimulate discourse. Andrew Solomon offers an elegant overview of the challenges that bioethics faces in articulating a solid basis for LGBT rights. Timothy F. Murphy asks whether bioethics still faces issues related to lesbian, gay, and bisexual people, given the deletion of homosexuality as a disease and the progress toward same-sex marriage. Jamie Lindemann Nelsons essay addresses the search for identity for transgender persons and the role of science in that search. Two articles, those by Brendan S. Abel and by Jack Drescher and Jack Pula, take up the complex issue of medical treatment for children who reject their assigned birth gender. Celia B. Fisher and Brian Mustanski address the special challenges of engaging LGBT youth in research, balancing the need for better information about this vulnerable group against the existing restrictions on research involving children. Tia Powell and Edward Stein consider the merits of legal bans on psychotherapies intended to change sexual orientation, particularly in the light of current research on orientation. Mary Beth Foglia and Karen I. Fredricksen-Goldsen highlight health disparities and resilience among LGBT older adults and then discuss the role of nonconscious bias in perpetuating disparities. Stephan Davis and Nancy Berlinger assess the challenges of access to care and health policy for transgender persons. Edward J. Callahan et al. tackle the ways in which diverse aspects of medicine should change to better incorporate the needs of LGBT patients, including through use of the electronic medical record, education of health professionals, and recruitment efforts for LGBT health professionals. Virginia Ashby Sharpe and Uchenna S. Uchendu describe multifaceted efforts within Veterans Administration facilities to create change for LGBT veterans across the largest integrated health care network in the United States. Lance Wahlert and Autumn Fiester find a mixed record in the use of case studies in teaching about LGBT issues.

Perceptions of Research Ethics Practices: IntegratedEthics™ Staff Survey Data from the VA Health Care System

Background: There are limited empirical data on factors that influence ethical practices in research settings. To broaden our understanding of ethical practices in research in the U.S. Department of Veterans Affairs (VA) and to understand researcher- and organizational-level factors associated with positive perceptions of practices, we assessed researchers’ perceptions of practices in research ethics. Methods: We analyzed data from 10,661 respondents to the 2010 IntegratedEthics™ Staff Survey (IESS) at VA who self-identified as research staff and who worked at facilities with Federalwide Assurance for the Protection of Human Subjects. We used descriptive statistics to evaluate these respondents’ perceptions of ethical practices in research and multivariate logistic regression analyses to evaluate associations between researcher- and organization-level characteristics and positive perceptions of ethical practices. Results: The results suggest that the majority of researcher respondents have positive perceptions of ethical practices in research at VA; for example, 85% almost never feel pressured to compromise ethical standards. Physicians and staff with managerial responsibilities tend to have more favorable impressions of ethical practices in research. The results also indicate areas for improvement. For example, 14–16% of respondents report that there are research staff members who regularly engage in behaviors that may inappropriately affect their research. Furthermore, results suggest that approximately 14% of VA research staff are not completely comfortable raising ethical concerns or reporting ethical violations related to research. Conclusions: Results from this study identify areas for quality improvement that can serve as a complement to the required education and training in research ethics, policy guidance, and rigorous institutional review board oversight and monitoring.

Perceptions of Clinical Ethics Practices

Background: Clinical ethics is fundamental to the quality of health care and is a concern facing all health care systems. This study examined clinicians’ perceptions of ethical practices in shared decision making with patients, end-of-life care, professionalism in patient care, and patient privacy and confidentiality in order to identify strengths in ethical practices and opportunities for improvement. Methods: We analyzed data from the 48,857 clinician respondents to the 2010 IntegratedEthics™ Staff Survey (IESS). The IESS was developed to provide a broad snapshot of a health care organizations ethical practices for quality improvement purposes. We used descriptive statistics to evaluate clinicians’ perceptions of clinical ethics practices and multivariate logistic regression analyses to evaluate associations between clinician- and organization-level characteristics and positive ethical practices. Results: Survey results suggest opportunities for improvement in ethical practices, including giving patients sufficient time to discuss treatment recommendations, giving better guidance to clinicians on how to maintain professional boundaries, disclosing medical errors to patients and surrogates, and providing clinicians with better education about ethical issues in end-of-life care. The majority of respondents were familiar with the ethics consultation service (ECS). Familiarity with the ECS was significantly associated with length of time working at VA, physician status, and manager/supervisory level of responsibility. If confronted with an ethical concern, approximately three-quarters of respondents reported that they would be very or moderately likely to use the ECS. Conclusions: The results from this study support quality improvement activities by allowing health care organizations to compare clinical ethics practices across staff groups, settings, and time. After a facility obtains its results, the next steps should include seeking greater understanding through qualitative interviews, and then selecting topics for quality improvement initiatives. These activities will reinforce the importance of ethics as a component of health care quality and promote a positive ethics environment.