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?