Doing Good/Avoiding Harm!Doing Good/Avoiding Harm!Towards a High Quality, Ethical Health Care Towards a High Quality, Ethical Health Care

SystemSystem

Susan MacRae, RNBioethicist

The Joint Centre for Bioethics

University of Toronto

CANADA

USA Healthcare Context

• Quality/Cost (Value) Debate• Geographic Variation• Focus on Outcomes• Information Technology• Public Accountability• Employee distress• “Cartesian dualism”/biophysiological model challenged

Thailand Healthcare Context

• Economic Crisis• Respect

– doctors– nurses– western medicine

• Physician Shortage• Time as limited resource• ?• ?

Health care is very good, BUT

we want to make it better!

Quality. What is it?

• Doing the right thing, Right!

• Reducing waste, rework and complexity

Role of the HCP in Quality: Why NOW?

• Economic crisis, concern for quality• Reporting systems rating health care providers. • Physician no longer lone agent of success and failure• New fields of quality emerged e.g, clinical epidemiology, variation studies s

how lack of solid scientific foundation• Change in information technology e.g, research, clinical practice changes, co

nsumer access• Pressures to focus on needs of individuals and communities, public reporting• Errors: 3 jumbo jets every 2 days• Complexity and rapid change means a need to be responsive to change, perfo

rm new tasks and responsibilities• Increased need for collaboration

Ask yourself….

• When quality fails in your own work, why does it fail?• Do you ever waste time waiting, when you should not

have to?• Do you ever redo your work because something failed

the first time?• Do the procedures you use waste steps, duplicate effor

ts, or frustrate you?• Is information that you need ever lost?• Does communication ever fail?

Quality Myths Refuted

• Poor quality is not b/c of lack of motivation or effort, rather poor job design, failure of leadership, unclear purpose

• Quality does not need to cost more • Quality does not need to take more time• Patients are only ones to judge certain aspects of

quality• There are valid and reliable strategies to measure

quality

Quality Measurement

• Structure– characteristics of physicians and hospitals

• e.g, physician specialty

• Process*– components of the encounter b/w clinician-pt

• e.g., test ordered

• Outcomes*– outcome data compared to subsequent health

• e.g., an improvement in mobility

*most common

Quality: According to Whom?

• Organization

• Physician/Nurses/Staff

• Patients and Families

Dimension of Patient-Centered Healthcare

Based on the work of The Picker Institute and Harvard University, Bostonwww.picker.org

Access to care Respect for patients’ values and preferences Coordination of care Information and education Physical comfort Emotional support Involvement of family and friends Continuity and transition

A Focus on patients and their families

• How do they define quality?• What helps or hinders their ability to manage

an ongoing problem?• What aspects of care are most important to

them?• What do they need?• Design systems around THIS!

Shared Decision Making: A Compassionate Partnership

• Research supported• What would you want/need? Your mother?• Meeting each other where each of you are. Both

experts!• Does not mean patients have complete control• Need creative ways to share information in limited

time, different languages, help illiterate, educational level

• Remember: patients have low expectations

Compassionate partnership cont..

• We are always clouded by our own views and opinions

• What can be done does not mean it should be done!

• Rash vs. necrotic toe, infection vs. driving• Clinicians and administrators (even families) do

not know what is important to patients

What Doctors and Patients Agree About

How important is itthat MD...

Patients’rankings

Doctors’rankings

I s skillf ul 1 6

I s thorough 2 11

I s truthful 3 4

Takes patientseriously

4 8

Builds trust 5 2

What Doctors and Patients Disagree About

How important is itthat MD...

Patients’rankings

Doctors’rankings

Explains risks andbenef its

6 58

Answers questions 9 40

Explains medications 12 82

Diagnosis makes sense 20 62

What Doctors and Patients Disagree About

How important is itthat...

Patients’rankings

Doctors’rankings

Chart is there 40 4

I nfo is explainedprivately

80 10

MD doesn’t embarrasspatient

60 13

Staf f are polite 72 17Epstein, K.R., Laine, C., Farber, N.J., Nelson, E.C., & Davidoff, F. (1996). Patients' perceptions of office medical practices: judging quality through the patients' eyes. American Journal of Medical Quality, 11(2 (summer)), 73-80.

Laine, C., Davidoff, F., Lewis, C.E., Nelson, E.C., Nelson, E., Kessler, R.C., & Delbanco, T.L. (1996). Important Elements of Outpatient Care: A Comparison of Patients' and Physicians' Opinions. Annals of Internal Medicine, 125(8), 640-645.

How do we balance competing needs?

•ORGANIZATIONS• DOCTORS, NURSES, STAFF• PATIENT, FAMILY

Bioethics: What is it?

Bioethics

• Doing good, Avoiding harm

• Provides a process to think through complex problems, balance competing needs, views, opinions, values and beliefs

• Provides support to reduce moral distress

• Provides education on ethics models and techniques

• Provides education on relevant legal and policy issues

Bioethics Myths refuted

• “Support” not “judgement”

• “Process” not “event”

• Dependent on context/culture, although also interest in Global Ethics

• Important for all staff, not just students

An Approach to Clinical and Ethical Decision-Making

MEDICAL FACTORSDiagnosisTreatmentPrognosis

PREFERENCESPatientFamilyTeam

QUALITY OF LIFEBeforeDuringAfter

CONTEXTSupport system

Cost, availabilitySpecial circumstances

[adapted from Jonsen, Siegler, Winslade, Clinical Ethics]

ETHICSEDUCATION

ORGANIZATIONALETHICS

CLINICALETHICS

Ethics Model

Ethics Education

• Students

• Staff

• Issues by specialty

• Staying current

• Patient/family centered

Other Ideas

• Be part of positive change

• Manage waste

• Look after yourselves, don’t get discouraged

• Find like-minded colleagues

• Be creative

• Use technology when appropriate

A High Quality, Ethical Healthcare System

• Everyone has an opportunity to improve the patient’s experience

• Compassionate care that at minimum is sensitive to patient needs, associated with good outcomes and delivered at a reasonable cost.

• High quality technical care

• High quality healing

More details• Honest, direct and compassionate communication between

patients, families, physicians and nurses.

• Teaching that is individualized according to the learning styles and abilities of the patient and the family, and incorporates multi-sensory and interactive education.

• Easily accessible programs of symptom management that enable the patient to maintain daily activities to the extent possible, minimize discomfort and address the full range of symptoms and side effects.

• Psychological support that is viewed as an integral part of treatment--not as special services for patients who cannot cope.

More details

• Care that is coordinated across settings, in which separate specialists communicate among themselves and with the patient. Consistent providers who can help the patient through transitions between care settings and who act as a team, although they might be from different organizations.

• Care that is provided when it’s necessary to ease the patient and family into the dying process by bridging the gap between acute and palliative care and not abandoning them.

Based on work by Lisa Leroy, The Picker Institute

Decision to Seek Care

Information Collection

Diagnosis

Treatment

Rehabilitation

Follow-up

•2 slides adapted from work by Dave Gustofson, Ph.D.University of Madison.

The Healthcare Model

Physical Environment

Family & Friends

Feelings

Symptoms

Future

Self Image

Providers

Treatment Process

The Human Model

Some Bioethics Issues

• How should scarce resources be distributed?– Macro, meso, micro levels

• What should we do if the doctor has a different view than the patient? Doctor from nurse? Clinician from the organization?

• What are the limits of medicine and who decides?

• Who should judge quality of life?

Clinical Ethics

• Improving clinical process and outcomes

• Ethics consultation/support

• Peer support

• Multi-disciplinary

• Patient-family centered

Organizational Ethics

• Link to values, strategic plan

• Quality Improvement

• Tie between clinical and administrative

• Patient/family centered

What CAN be done is not necessarily what SHOULD be done!