1. © 2010 Jones and Bartlett Publishers, LLC A Practical Approach For Decision Makers SECOND EDITION EILEEN E. MORRISON

2. © 2010 Jones and Bartlett Publishers, LLC Class Eleven: The Ethics of Quality

3. © 2010 Jones and Bartlett Publishers, LLC Agenda Introduction to quality exercise Introduction to quality exercise Review of history and quality assurance Review of history and quality assurance Discussion of the organizational view of quality assurance. Discussion of the organizational view of quality assurance. Discussion of the definition of quality in health care Discussion of the definition of quality in health care Quality assurance reports; ethics of quality assurance Quality assurance reports; ethics of quality assurance Cases discussion Cases discussion Summary Summary

4. © 2010 Jones and Bartlett Publishers, LLC Quality Definition Exercise Use self-brainstorm technique Use self-brainstorm technique Right side of the room= What is quality when you are the patient? Right side of the room= What is quality when you are the patient? Left side of the room= What is quality when you are the HCM? Left side of the room= What is quality when you are the HCM? Do a shout out! Do a shout out! Conclusions? Conclusions?

5. © 2010 Jones and Bartlett Publishers, LLC Background Early history of health care featured control by professionals; no regulation. Early history of health care featured control by professionals; no regulation. Change in American culture produced need for accountability. Change in American culture produced need for accountability. Regulation has evolved through many iterations of JCAHO. Regulation has evolved through many iterations of JCAHO. 1918 part of the American College of Surgeons; first hospital inspections. 1918 part of the American College of Surgeons; first hospital inspections. 1965: A major change in health care affected the Joint Commission too. 1965: A major change in health care affected the Joint Commission too.

6. © 2010 Jones and Bartlett Publishers, LLC JCAHO is now working on…. Was meeting JCAHO standards quality? Was meeting JCAHO standards quality? JCAHO is working on quality assurance through ORYX®. JCAHO is working on quality assurance through ORYX®. –Is there 100% compliance? It also became a giant accreditor. It also became a giant accreditor. Examples include ambulatory care, behavioral care, home care, hospitals, laboratories, long term care, office surgery, disease specific programs. Examples include ambulatory care, behavioral care, home care, hospitals, laboratories, long term care, office surgery, disease specific programs.

7. © 2010 Jones and Bartlett Publishers, LLC Through the eyes of the Organization Multiple accreditors may mean conflicting regulations. Multiple accreditors may mean conflicting regulations. See regulations as a threat to values. See regulations as a threat to values. Time and financial burdens seem excessive. Time and financial burdens seem excessive. JCAHO used as the blame or the prod. JCAHO used as the blame or the prod. Technology and documentation accuracy are major issues. Technology and documentation accuracy are major issues.

8. © 2010 Jones and Bartlett Publishers, LLC What is Quality in Health Care? What is your definition? What is your definition? Clinical professionals think that it is …. Clinical professionals think that it is …. Administrators think it is …. Administrators think it is …. Donabedian’s classic definition says it is about structure, process, and outcomes. Donabedian’s classic definition says it is about structure, process, and outcomes. All three areas need to be measured. All three areas need to be measured.

9. © 2010 Jones and Bartlett Publishers, LLC Quality Assurance Efforts There are many stakeholders in the quality assurance effort. There are many stakeholders in the quality assurance effort. These include payers, advocates, facilities, and patients. These include payers, advocates, facilities, and patients. Why would each of these groups care about quality in health care? Why would each of these groups care about quality in health care?

10. © 2010 Jones and Bartlett Publishers, LLC Research Findings What is it? What does it do? What ethics issue does it create? What is it? What does it do? What ethics issue does it create? Aquinas: Centers for Medicare and Medicaid Aquinas: Centers for Medicare and Medicaid Kant: Agency for Healthcare Research and Quality Kant: Agency for Healthcare Research and Quality Mill: Institute for Health Improvement Mill: Institute for Health Improvement Rawls: Lean Systems. Rawls: Lean Systems. Conclusions? Conclusions?

11. © 2010 Jones and Bartlett Publishers, LLC Ethics of Quality Improvement Kant would see quality as a duty; Buber and Frankl would agree. Kant would see quality as a duty; Buber and Frankl would agree. Utilitarians would look for greatest good for greatest number and for preventing harm. Utilitarians would look for greatest good for greatest number and for preventing harm. Rawls would say social justice requires quality for all. Rawls would say social justice requires quality for all. Also fits the principles such as truth telling, autonomy, and justice. Also fits the principles such as truth telling, autonomy, and justice.

12. © 2010 Jones and Bartlett Publishers, LLC Case Studies Obstinate Orthopedist Obstinate Orthopedist –Ethics issues for the physicians? –Ethics issues for Ms. Gormal? Self Assured EAP Self Assured EAP –Ethics violations for the EAP? –What actions did Mr. Rampaire take?

13. © 2010 Jones and Bartlett Publishers, LLC In summary… Do you think quality is good business and good ethics? Do you think quality is good business and good ethics? How can you make quality practice the norm in your organization? How can you make quality practice the norm in your organization?