1. Preventive Ethics Beyond the Basics

2. Module 4 Describing Current Ethics Practice

3. Learning Objectives Define what data are needed to describe current ethics practice. Choose appropriate data collection methods to describe current ethics practice. Develop an effective data collection plan to describe current ethics practice for a particular ethics issue. 3

4. ISSUES Link STUDY the Issue Diagram the process behind the relevant practice Gather specific data about best practices Gather specific data about current practices Refine the improvement goal to reflect the ethics quality gap 4

5. Storyboard Progression 5 Advance Directives Issue STUDY the Issue Gather and summarize information about best ethics practice. Identify sources for applicable ethical standards Draft an operational definition of best ethics practice based on the ethical standard(s) and the specific ethics issue. Primary care patients who request assistance with completing an advance directive should receive it. Advance Directives Issue STUDY the Issue Gather and summarize information about best ethics practice. Identify sources for applicable ethical standards Draft an operational definition of best ethics practice based on the ethical standard(s) and the specific ethics issue. Primary care patients who request assistance with completing an advance directive should receive it.

6. Assessing Data Quality “Good Enough” Data Must be enough to determine how often best ethics practice is actually occurring Must have quality to convince others of level of current ethics practice 6

7. Before Collecting Data Describe best ethics practice. Decide what data you need to measure current ethics practice.  Identify who or what “counts.”  Measure must accurately describe current ethics practice. 7

8. Measuring Current Ethics Practice 8 Denominator: total # of Braeburn apples at fruit stand (excluding all other types of apples) Numerator: # Braeburn apples at fruit stand of medium size (150–250 g), mostly red, and firm all over medium size mostly red firm all over

9. Metrics: Advance Directives Issue 9 # of primary care patients provided with assistance # of primary care patients who requested assistance with completion of an advance directive 1. Ethics Issue2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric6. Current Ethics Practice “Is” 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 1004.2 Advance Care Planning and Management of Advance Directives VHA Handbook states that additional information about advance directives and/or assistance in completing forms must be provided for all patients who request this service. Exclusion(s): Patients who change their minds about their requests for assistance, who withdraw from the Health Care System, or who now lack decision- making capacity. Primary care patients who request assistance with completing an advance directive should receive it [unless patients change their minds about their requests for assistance, withdraw from the Health Care System, or who now lack decision-making capacity]. Numerator: _________________ Denominator: Method: Sample size: Time frame for data collection MODULE 2MODULE 3MODULE 4 The number of primary care patients provided with assistance Total number of primary care patients who requested assistance with completing an advance directive

10. Metrics and Best Ethics Practice Metric must match the description of best ethics practice! 10 CAUTION

11. Metrics: Adverse Events Issue 11 1. Ethics Issue 2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric6. Current Ethics Practice “Is” The quality manager for surgical services found a number of instances in which adverse events that caused harm that should have been disclosed to patients or personal representatives were not disclosed. VHA Handbook 2008- 002 Disclosure of Adverse Events to Patients There is an unwavering ethical obligation to disclose to patients harmful adverse events that have been sustained in t he course of care, including cases where the harm may not be obvious, or where there is potential for harm to occur in the future. Exclusion(s): Patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative. Adverse events that cause harm to patients on surgical services should be disclosed to the patient or personal representative [unless patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative]. Numerator: ___________________ Denominator: Method: Sample size: Time frame for data collection: MODULE 2MODULE 3MODULE 4 # of adverse events that caused harm to patients on surgical services # of adverse events that caused harm to patients on surgical services that were disclosed to patients or personal representatives

12. Group Activity Instructions Handout 4.1 (20 min) Ethics Issues 3, 4, and 5 1.Review Ethics Issues 3, 4, and 5 on handout. 2.Determine numerator and denominator, and consider exclusions. 3.Record answers. 12

13. Core Elements of Data Collection Plan Method(s) Sampling Task definition and assignment Time frame 13

14. Data Collection Methods Health or other record Observation Interviews Focus groups Surveys 14

15. Data Collection Methods Health or other record 15

16. Data Collection Methods Observation 16

17. Data Collection Methods Interviews – Telephone – Face-to-face Focus groups 17

18. Data Collection Methods Surveys – Mail – Internet 18

19. Data Collection Methods: Advance Directives Issue Which data collection method will likely provide the data necessary to describe current ethics practice? Healthcare record reviews, if we are confident that the request and response are documented Interviews―face-to-face or on the telephone―because they enable us to directly question patients about their experiences 19

20. Revisiting the Metrics: Advance Directives Issue 20 # of primary care patients provided with assistance # of primary care patients who requested assistance with completion of an advance directive 1. Ethics Issue2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric6. Current Ethics Practice “Is” 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 1004.2 Advance Care Planning and Management of Advance Directives VHA Handbook states that additional information about advance directives and/or assistance in completing forms must be provided for all patients who request this service. Exclusion(s): Patients who change their minds about their requests for assistance, who withdraw from the Health Care System, or who now lack decision- making capacity. Primary care patients who request assistance with completing an advance directive should receive it [unless patients change their minds about their request s for assistance, withdraw from the Health Care System, or who now lack decision-making capacity]. Numerator: _________________ Denominator: Method: Sample size: Time frame for data collection MODULE 2MODULE 3MODULE 4 The number of primary care patients provided with assistance as measured by a note template completed by a social worker or someone equally trained Total number of primary care patients who requested assistance with completing an advance directive

21. Group Activity Instructions Handout 4.4 (20 min) 1.Choose spokesperson. 2.In small groups, review ethics issue and best ethics practice. 3.Determine pros and cons of using each data collection method. 4.Choose top 2 data collection methods and prepare to share them with whole group. 21

22. Data Collection Bottom Line There are no perfect methods! The best data collection method is the one that provides data that match the practice we are interested in—and does so with the least amount of burden to the team. 22

23. Sampling From which population are we sampling? How much information do we need to describe current ethics practice? 23

24. Sampling Methodology The Joint Commission (TJC) sampling methodology For a denominator of 30 or fewer, you would review all 30. For 30–100, you would review 30. For 101–500, you would review 50. Above 500, you would review 70. 24

25. Sampling Plan 25 Denominator: total # of Braeburn apples at fruit stand (excluding all other types of apples) Numerator: # Braeburn apples at fruit stand of medium size (150–250 g), mostly red, and firm all over Sampling plan: 10% (50 apples) or using TJC (70 apples). Either number would be an acceptable plan. When to sample: depends on our purpose for collecting the data

26. Sampling Plan: Advance Directives Issue 26 # of primary care patients provided with assistance # of primary care patients who requested assistance with completion of an advance directive 1. Ethics Issue2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric6. Current Ethics Practice “Is” 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 1004.2 Advance Care Planning and Management of Advance Directives VHA Handbook states that additional information about advance directives and/or assistance in completing forms must be provided for all patients who request this service. Exclusion(s): Patients who change their minds about their requests for assistance, who withdraw from the Health Care System, or who now lack decision- making capacity. Primary care patients who request assistance with completing an advance directive should receive it [unless patients change their minds about their requests for assistance, withdraw from the Health Care System, or who now lack decision-making capacity]. Numerator: ____________________ Denominator: Method: Record review Sample size: Time frame for data collection: MODULE 2MODULE 3MODULE 4 The number of primary care patients provided with assistance as measured by a note template completed by a social worker or someone equally trained Total number of primary care patients who requested assistance with completing an advance directive 30 1 week

27. Task Definition and Assignment What tasks do we need for our record review collection? Develop collection tool. Collect the data from the healthcare record. Summarize the findings. Who will do each of these tasks? 27

28. Time Frame for Tasks What questions do we need to ask regarding the time frame for each task in our data collection plan? How long will each task take? What is the target date for completion of each task? 28

29. Data Collection Plan Will our data collection plan provide the data needed for understanding current ethics practice? If the answer is no… 29

30. Current Ethics Practice: Advance Directives Issue 30 # of primary care patients provided with assistance # of primary care patients who requested assistance with completion of an advance directive 1. Ethics Issue2. Ethical Standard Source(s) 3. Ethical Standard Description(s) with Exclusions 4. Best Ethics Practice “Should” 5. Metric6. Current Ethics Practice “Is” 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 1004.2 Advance Care Planning and Management of Advance Directives VHA Handbook states that additional information about advance directives and/or assistance in completing forms must be provided for all patients who request this service. Exclusion(s): Patients who change their minds about their requests for assistance, who withdraw from the Health Care System, or who now lack decision- making capacity. Primary care patients who request assistance with completing an advance directive should receive it [unless patients change their minds about their requests for assistance, withdraw from the Health Care System, or who now lack decision-making capacity]. Numerator: ____________________ Denominator: Method: Record review Sample size: Time frame for data collection: MODULE 2MODULE 3MODULE 4 The number of primary care patients provided with assistance as measured by a note template completed by a social worker or someone equally trained Total number of primary care patients who requested assistance with completing an advance directive 30 1 week 3 /30 = 10% Currently, 10% of primary care patients who have a documented request for assistance with completing an advance directive receive it.

31. Group Activity Instructions Handout 4.6 (10 min) 1.Choose (another) spokesperson. 2.Review information about ethical practice. 3.Fill in 5 steps for data collection plan on Handout 4.6. 4.Prepare to report to whole group. 31

32. Storyboard Progression 32 Advance Directives Issue STUDY the Issue Define the metric and gather specific data about current ethics practice. Numerator = number of times the practice actually happens. Denominator = population to whom specific ethics practice applies. 3 ÷ 30 = 10% of primary care patients who have a documented request for assistance with completing an advance directive receive it.

33. Takeaways Describing current ethics practice Defining the metric Measuring current ethics practice Data collection methods Determining sample sizes Data collection plan 33

34. Module 4 Questions?