Christina Williamson, DHA(c),MSN, RN-BC

Veterans Healthcare System of the Ozarks

Define Preventive Ethics and describe the Preventive Ethics model.

Identify the key elements of the ISSUES approach to reduce an ethical quality gap.

Apply the ISSUES approach to an organizational ethical concern.

A healthy ethical environment can:◦ improve employee moral◦ enhance productivity◦ improve efficiency

Do the right thing, do it well, and do it for the right reasons.

Technical QualityService QualityEthics Quality

Decisions and actions Systems and processes Environment and culture

Decisions and actions

Systems and processes

Environment and culture

Shared decision making Ethical practices in end-of-life care Privacy and confidentiality Professionalism Resource allocation Business and management Research Practices in the workplace

Produce measurable improvements in the organizations ethics practice.

Quality improvement interventions:◦ Redesign work processes◦ Implement checklists, reminders, and decision

support◦ Develop policies and protocols that promote

ethical practices◦ Educate patients and staff

A systematic process for identifying and addressing health care ethics quality gaps on system level ethics issues.

The process involves six steps: Identify Study Select Undertake Evaluate Sustain

Be proactive in identifying ethics issues.

Does the issue give rise to an ethical concern or suggest a quality gap?

Specify the improvement goal the team would like to achieve.

The use of electronic medical records and the confidentiality of medical records.

Access to the computerized patient record system.

Diagram the process

Gather data about best practices

Gather data current practices

Refine the improvement goal

Providing the patient with the needed reassurance their information is kept confidential gives them a sense of security, allowing the patient to feel free to make full and frank disclosure of medical or psychosocial history or symptoms.

Reminding staff of the need to diligently protect patient confidentiality.

Patient Generated

AddressPhone numberNext of kinDate of birthMarital statusGenderReligionEligibilityMilitary serviceService connectionMedical historySensitive record

Healthcare Team Generated

AppointmentsAllergiesVitalsMedicationsAppointmentConsultsInpatient staysLabMental Health visitsOncology reportsPathology reportsOutpatient visits

Electronic data sharing allows the consumer full control of the health information.

Patient Safety Institute promotes a common record controlled by the patient and the provider.

Geisinger Health System created a fully integrated medical record with electronic communication between the physicians and accessible to the patient and the caregiver.

A Computerized Patient Record System integrates various clinical packages including: ◦ Order Entry◦ Progress Notes ◦ Discharge Summaries◦ Consult Results ◦ Vital Signs ◦ Problem List◦ Progress Notes◦ Discharge Summaries ◦ Consult Results ◦ Lab Results◦ Imaging Reports and ◦ Medication Profiles

Identify the major causes of the ethics gap.◦ Root Cause Analysis◦ Fishbone or Cause-and effect diagram

Brainstorm strategies to narrow the gap.

Choose one or more strategy.

Identify personnel limits on access and disclosure.

Identify processes in place that state information can not be disclosed without consent.

Security measures to protect personal information.

Information shared outside of CPRS is encrypted or sent within a secure site.

Inform patients of limits of confidentiality protection.

Identify the steps needed to carry out the strategy.

Develop measures to assess and evaluate.

Execute the plan, make corrections based on what works and what doesn’t.

Information will be shared verbally and in writing.

Patients will better understand the reason why.

Information shared will include:◦ the importance of a common health record◦ the VHA supports the exchange of clinical data as

an effective method to improve the veteran’s health.

Check the results

Adjust as necessary

Evaluate the ISSUES process

Clinic providers felt they do not have time to go into detail as it relates to the use of an electronic medical record.

Written information or patient care material addressing this issue is not readily available.

Patients’ expressed unwillingness to have their clinical data shared.

The development of a script that summarizes why and the importance of sharing healthcare information.

Information to the inpatient handbook reads, ‘Information disclosure and confidentiality’: Your medical record will be kept confidential. Access to your electronic medical record, within the VA system, may be viewed by authorized VA personnel only.

MyHealthy Vet program.

Integrate the change into standard operating procedures.

Disseminate the improvement.

Continue monitoring.

Customer service surveys

Annual SHEP (inpatient and outpatient) report

Self reported patient complaints

Patient advocate feedback

MRSA testing post mortem.

Conflicting patient and provider expectations.

Assessing decision making capacity.

Do all patient with dementia lack decision making capacity?

From ……◦ Reactive◦ Case based◦ Narrow◦ Silos◦ Punishment◦ Rules

To ……◦ Proactive◦ Systems oriented◦ Comprehensive◦ Collaboration◦ Motivation◦ Rules & Values