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 Quality  Service Quality  Ethics 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  Address  Phone number  Next of kin  Date of birth  Marital status  Gender  Religion  Eligibility  Military service  Service connection  Medical history  Sensitive record Healthcare Team Generated  Appointments  Allergies  Vitals  Medications  Appointment  Consults  Inpatient stays  Lab  Mental Health visits  Oncology reports  Pathology reports  Outpatient 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