1. Preventive Ethics Beyond the Basics

2. Module 1 Determining Whether an Issue Is Right for the ISSUES Approach

3. Learning Objectives Describe the criteria for determining whether an issue is appropriate for a quality improvement approach such as ISSUES. Apply the criteria to determine whether an issue is appropriate for a quality improvement approach such as ISSUES. 3

4. ISSUES Link IDENTIFY an Issue Be proactive in identifying ethics issues Characterize each issue Clarify each issue by listing the improvement goal Prioritize the issues and select one 4

5. Appropriateness for PE 5 12345678910111213 Date Issue Came to Attention of PE (mm/dd/yy) Source of Issue (1–2 words) Possible Ethics Issue (who, what, where, when, how much or how often) Immediate Action Req’d (Y/N) Simple Problem/Obvious Solution (Y/N) Other Program Responsible for This Issue (Y/N) Ethics Quality Gap Preliminary Improvement Goal Appropriate for PE (Y/N) Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N).

6. Selecting Issues for a QI Approach A quality improvement approach is appropriate for issues resulting from failures caused by systems or processes that may not be reliably producing the desired outcome. 6

7. Selecting Issues for a QI Approach: Another Consideration Appropriate for issues that require further study to accurately describe current workflow process, ethics quality gap, underlying causes of gap Small-scale testing also needed 7

8. Tools for Assessing Appropriateness Choosing Issues for PE— Worksheet Choosing Issues for PE: Tracking Tool IntegratedEthics Health Care Ethics Domains and Topics 8 Appropriateness for PE 12345678910111213 Date Issue Came to Attention of PE (mm/dd/yy) Source of Issue (1–2 words) Possible Ethics Issue (who, what, where, when, how much or how often) Immediate Action Req’d (Y/N) Simple Problem/Obvious Solution (Y/N) Other Program Responsible for This Issue (Y/N) Ethics Quality Gap Preliminary Improveme nt Goal Appropriate for PE (Y/N) Best Ethics Practice Current Ethics Practice Ethi cs Dom ain Ethi cs Topi c Prac tice Inco nsist ent with Ethi cal Standard s, Nor ms, or Expe ctati ons (Y/N) Data Avail able (Y/N) If Data Una vaila ble, Easil y Coll ecte d (Y/N).

9. Urgent Issue? Does the issue require urgent and immediate action by leadership? Take to leadership!! 9 456 Immediate Action Req’d (Y/N) Simple Problem/Obvious Solution (Y/N) Other Program Responsible for This Issue (Y/N)

10. Simple Issue? Is the issue simple, with an obvious solution? Just do it! 10 456 Immediate Action Req’d (Y/N) Simple Problem/Obvious Solution (Y/N) Other Program Responsible for This Issue (Y/N)

11. Another Program Responsible? Is there another program or service responsible for this issue? Refer or collaborate 11 CAUTION 456 Immediate Action Req’d (Y/N) Simple Problem/Obvious Solution (Y/N) Other Program Responsible for This Issue (Y/N)

12. Ethics Quality Gap The disparity between what should be (best ethics practice) and what is (current ethics practice) 12 7891011 Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

13. Best Ethics Practice Ethics domain Ethics topic Ethical standard 13 7891011 Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

14. Ethics Domain? Clinical Business Research 14 7891011 Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

15. Ethics Topic? 15 7891011 Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

16. Written standards Ethics expertise Inconsistent with Ethical Standards, Norms, or Expectations? 16 7891011 Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

17. Current Ethics Practice Measurable data Easily collected data 17 7891011 Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

18. Measure ethical practice Express as percent or number Measurable Data Available? 18 7891011 Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

19. Consider data collection method required for easily collecting the data Easily Collected Data? 19 7891011 Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

20. Example: Advance Directives Issue A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. 20

21. Ethics Domain? Column 7: Is there an ethics domain related to this issue? A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. Shared Decision Making with Patients 21

22. Ethics Topic? Column 8: Is there an ethics topic related to this issue? A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. Advance Care Planning 22

23. Standards, Norms, or Expectations? Column 9: Is the practice inconsistent with ethical standards, norms, or expectations? A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. VHA Handbook 1004.02 Advance Care Planning and Management of Advance Directives 23

24. Quantifiable Data? Column 10: Is quantifiable data about current ethics practice readily available? A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. No 24

25. Quantifiable Data? Column 11: Is quantifiable data about current ethics practice easily collected? A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. Yes, through several methods such as health record reviews or interviews of patients or staff 25

26. Appropriate for ISSUES Approach? Does this issue suggest an ethics quality gap amenable to an ISSUES approach? YES! 26 12345678910 11 Date Issue Came to Attention of PE (mm/dd/yy) Source of Issue (1–2 words) Possible Ethics Issue (who, what, where, when, how much or how often) Immediate Action Req’d (Y/N) Simple Problem/Obvious Solution (Y/N) Other Program Responsible for This Issue (Y/N) Ethics Quality Gap Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N).

27. When Issue Isn’t Appropriate Get back to process owner for identified issue. Explain reasoning for PE team’s decision. Help program or service think through where else they might turn for assistance. Ask ethics program leadership to assist. 27

28. Draft general statement of the desired ethical practice Preliminary Improvement Goal 28 456789101112 Immediate Action Req’d (Y/N) Simple Problem/Obvious Solution (Y/N) Other Program Responsible for This Issue (Y/N) Ethics Quality Gap Preliminary Improvement Goal Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N)

29. Tracking Tool: Advance Directives Issue 29 Appropriateness for PE 12345678910111213 Date Issue Came to Attention of PE (mm/dd/yy) Source of Issue (1–2 words) Possible Ethics Issue (who, what, where, when, how much or how often) Immediate Action Req’d (Y/N) Simple Problem/Obvious Solution (Y/N) Other Program Responsible for This Issue (Y/N) Ethics Quality Gap Preliminary Improvement Goal Appropriate for PE (Y/N) Best Ethics Practice Current Ethics Practice Ethics Domain Ethics Topic Practice Inconsistent with Ethical Standards, Norms, or Expectations (Y/N) Data Available (Y/N) If Data Unavailable, Easily Collected (Y/N) 9/15/ XX TJC A recent accreditation review of primary care health records found that only a few patient requests for assistance with completing an advance directive were followed up on by clinic staff. NNNSDMACPYNY Increase assistance to primary care patients who request help with completing an advance directive Y

30. Group Activity Instructions Handouts 1.2, 1.3, 1.5–1.10 (20 min) 1.Answer questions 4–12 on worksheets. 2.Mark answers on tracking tool (Handout 1.2). Be prepared to discuss: Is issue appropriate for PE, and why (or why not)? If uncertain after applying criteria, what other information might help you decide? What will you do if it is not appropriate for ISSUES approach? 30

31. Takeaways Determining whether an issue is right for the ISSUES approach Being good stewards of your resources; excluding issues that aren’t appropriate Using appropriateness criteria on worksheet and tracking tool Looking for ethics quality gap Drafting preliminary improvement goal 31

32. Module 1 Questions?