1. Preventive Ethics Beyond the Basics

2. Module 2 Prioritizing Among Ethics Issues

3. Learning Objectives Describe the criteria to be considered when prioritizing ethics issues. Apply prioritization criteria to ethics issues. Describe how to address issues that remain on the tracking tool. 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. Tracking Tool: Advance Directives Issue 5 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

6. Criteria for Prioritizing Ethics Issues 6 Priority for ISSUES Approach 1415161718192021 Alignment with Strategic Goals (L/M/H) Level of Risk (L/M/H) Impact on Patient and/or Employee (L/M/H) Volume or Scope of Effect (L/M/H) Resources and Time Req’d to improve (L/M/H) Likelihood of Success (L/M/H) Time-Sensitive Issue (Y/N) Refer for Leadership Approval (Y/N)

7. Criteria for Prioritizing Ethics Issues 14. Alignment with strategic goals/priorities 7 141516 Alignment with Strategic Goals (L/M/H) Level of Risk (L/M/H) Impact on Patient and/or Employee (L/M/H)

8. Criteria for Prioritizing Ethics Issues 15. Level of risk posed to organization 8 141516 Alignment with Strategic Goals (L/M/H) Level of Risk (L/M/H) Impact on Patient and/or Employee (L/M/H)

9. Criteria for Prioritizing Ethics Issues 16. Impact on patient and/or employee satisfaction 9 151617 Level of Risk (L/M/H) Impact on Patient and/or Employee (L/M/H) Volume or Scope of Effect (L/M/H)

10. Criteria for Prioritizing Ethics Issues 17. Volume or scope of effect 10 161718 Impact on Patient and/or Employee (L/M/H) Volume or Scope of Effect (L/M/H) Resources and Time Req’d to improve (L/M/H)

11. Criteria for Prioritizing Ethics Issues 18. Resources required to improve 11 171819 Volume or Scope of Effect (L/M/H) Resources and Time Req’d to improve (L/M/H) Likelihood of Success (L/M/H)

12. Criteria for Prioritizing Ethics Issues 19. Likelihood of success 12 181920 Resources and Time Req’d to improve (L/M/H) Likelihood of Success (L/M/H) Time-Sensitive Issue (Y/N)

13. Criteria for Prioritizing Ethics Issues 20. Time-sensitive issue 13 192021 Likelihood of Success (L/M/H) Time-Sensitive Issue (Y/N) Refer for Leadership Approval (Y/N)

14. Recommendation 21. Refer to leadership for approval 14 192021 Likelihood of Success (L/M/H) Time-Sensitive Issue (Y/N) Refer for Leadership Approval (Y/N)

15. Group Activity Instructions Handouts 2.1 and 2.2 (25 min) Individually (15 min) 1.Rate 5 ethics issues in Handout 2.1. 2.Determine priority of all 5 ethics issues; record in Final Rankings box at bottom of handout. In groups (10 min) 3.Compare and discuss individual rationales for rating ethics issues. 4.Indicate on Handout 2.2 which issues, based on the ratings, will be referred to leadership for approval. 15

16. When an Ethics Issue Is Not Selected for a PE ISSUES Approach If not the highest priority, ethics issue stays in tracking tool to be addressed at later date. Leadership designates different approach. PE team supports other group in addressing ethics issue. If ethics issue doesn’t warrant further involvement of PE team, PE coordinator closes loop. 16

17. If Leadership Disagrees with the PE Team’s Prioritization Leaders may have additional knowledge and reasoning for adjusting priorities and should provide that rationale during discussion. Keep item on list. It will likely be addressed when there is reasonable time to do so, especially if it is unlikely to be addressed through other means. 17

18. If Leadership Proposes an Issue That Is Not Appropriate for PE Ask leadership for clarification on what the ethics gap may be, and use the appropriateness criteria as needed to assist in the discussion and negotiation. If it’s clearly not a PE issue, the PEC may recommend other avenues (i.e., who should address the issue). If it’s outside the PE team’s area of expertise, make it clear that the team will require specific resources to address the issue (e.g., patient safety, subject matter expert). If the issue is appropriate for the ISSUES approach, add it to the tracking tool. 18

19. Storyboard Progression 19 Advance Directives Issue VA Facility/Health Care System: VA Working Title: Shared Decision Making: Completing Advance Care Directives Date: 2012 Team Members (First, Last Name, Title Role) PEC, QM, Admin, Nursing, Physician, Social Work Ad hoc Members (First, Last Name, Title Role) SME—ethics consultant Process owners—MD, Nursing, Clerk, Social Work

20. Storyboard Progression 20 Advance Directives Issue IDENTIFY an Issue Briefly summarize the issue and the source. Ethics Issue (who, what, when, how much): 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. Source of Issue: The Joint Commission (TJC) survey findings List the (preliminary) improvement goal. Increase assistance to primary care patients who request help with completing an advance directive. Describe why the issue was selected as a priority by the preventive ethics team. This ethics issue aligns with strategic goals, is expected to bring significant benefit to patients, and has a high likelihood of success. The IEC agreed with prioritization of this issue and fully supports the team’s addressing this issue.

21. Takeaways Prioritizing among ethics issues Using tools 7 criteria for prioritizing ethics issues Rating and ranking issues Acting on ethics issues not selected for PE ISSUES approach 21

22. Module 2 Questions?