Ethics and Quality: Improvement and Impact.

1. Ethics and Quality: Improvement and Impact.

2. SJHS – The Ministry • Serve communities in 3 States through 14 Hospitals, 3 Integrated Medical Groups, Home Health and Outreach • Market Share Leader in Every Region Humboldt County Eastern New Mexico Sonoma County Napa County West Texas High Desert Orange County

3. The 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.

4. 10 Years in Review • Practices in Ethics Innovation: “Tests of Change” • Practices in Diffusion: “Having Impact Spread”

5. Practices in Ethics Innovation

6. SJHS “Principled Innovation” The four principles which frame the orientation of our ethics services are: • To be proactive and not just reactive. • To be organizationally integrated and not isolated. • To be held accountable for performance based on demonstrable outcomes and not simply good intentions. • To be oriented by and rooted in SJHS core values and not merely external legal, regulatory, or accreditation requirements.

7. Next Generation Structure • Dual Roles of CEAT and SEG • Ethics ACEs Program • Executive Ethics Liaisons

8. Innovation, 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.

9. 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. The Difference betweenResearch and Improvement

10. AIM: 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.

11. 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.

12. Measures: 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.

13. Two 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.

14. 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.

15. Local Ministry Initiatives • Completion of Advance Directives before entering hospital. • In-hospital DNR. • Pre-hospital EMS DNR Form completed for Home health patients. • Increase Length of Stay in Hospice. • Blood Products and Jehovah Witness Community.

16. A3 Tool • 6. Solution Approach • 7. Rapid Experiments • 8. Completion Plan • 9. Confirmed State • Reason for Action. • Initial State • Target State • Gap Analysis • Insights

17. Strength of Steel Iceberg Present North Atlantic Opening in Hull Steel Plates Buckled on Hull Titanic Sank Water Filled Hull AND AND Speed (18 knots) Record attempt AND Many causes Ship in Water Cause Map Tool Ship Hit Iceberg Ship Couldn't Turn Quickly Enough AND Size of Rudder AND Saw iceberg late No Binoculars AND Titanic Sank Strength of Steel Ship in Water Atlantic Crossing Business of Company

18. 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.

19. Practices of Diffusion

20. From Diffusion of Innovations by Everett Rogers: Characteristics of People Adopting Change Innovators Early Majority Require Local Personal Trust 34% Late Majority “Standard of Practice” 34% Early Adopters “The Watched” 13.5% Traditionalists “Tried and True” 16% 2.5%

21. Influential Factors for Spreading Change • Perceived benefit of change. • Compatible with current needs, belief systems and processes • Simplicity of proposed intervention • Trial ability • Observability.

22. The “To Do” List for Ethics Leaders • Find sound innovations. • Find and support Innovators. • Invest in Early Adopters. • Make early adopter activity observable. • Trust and enable reinvention. • Create slack for change. • Lead by example.

23. Make Early Adopter Activity Observable • Monthly Conference Calls: A3 Presentation/Innovation Discussion • Peer Learning Among Local Ministries • Electronic Networking: Sharing Our Measured Work on Website. • Annual Ethics Leaders Workshop • Local Ministry Ethics Dashboard.

24. What 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?