The authors view the activities involved in critical care medicine as composing a complex adaptive system that is itself operating within a complex adaptive system, the healthcare organization. The authors explain why it is necessary that these systems be viewed this way, and they explain what is necessary to allow them to produce creative or emergent outcomes. They provide a justification for the role of an organization ethics program within this context. They provide a definition of organization ethics and outline the characteristics that an effective organization ethics program would possess.
Despite the fact that ethics consultations are an accepted practice in most healthcare organizations, 1 many clinical ethicists continue to feel marginalized by their institutions. They are often not paid for their time, their programs often have no budget, and institutional leaders are frequently unaware of their activities. 2 One consequence has been their search for concrete ways to evaluate their work in order to prove the importance of their activities to their institutions through demonstrating their efficiency and effectiveness. 3 The activities of clinical ethicists include education, policy review, research, and clinical ethics consultation. These activities all have a place in the wellconstructed clinical ethics infrastructure of a healthcare organization, but ethics consultation can be regarded as the driving force of these activities. It is from case consultations that clinical ethicists draw much of their educational materials. Cases highlight for clinical ethicists "gaps" or other inadequacies in policies that need addressing, and where research is needed. Furthermore, cases are often the most visible aspect of the work of clinical ethicists because other healthcare organization stakeholders (patients, surrogates, family members, other clinicians, and staff) are generally involved in consultations. So it is not surprising that clinical ethicists have been concerned to generate rigorous evaluations that demonstrate the efficiency and effectiveness of the ethics consultation.The components of the consultation can be separated into process, structure, and outcomes, 4 and in spite of the central tenant of the "quality movement" that assumes envisioned outcomes will occur if processes and structure are appropriate, 5 clinical ethicists have been encouraged to focus their evaluation efforts on outcomes. 6 Again, this is not surprising. Process and structure evaluations are often of little interest to administrators because they do not prove either efficiency or effectiveness of outcomes.Evaluation of consultation outcomes has generally followed the familiar cost and quality approach. Clinical ethicists have sought to prove either the efficiency of the ethics consultation through the cost savings that it generates 7 or the effectiveness of the ethics consultation service through satisfaction studies. 8 More recently, a multisite study has been released that combines both a cost and quality approach to evaluating the outcomes derived from ethics consultations. 9 This study demonstrates that the intervention of a clinical ethics consultation with patients facing end-of-life decisions saves resources while producing quality outcomes. The results of the study have been widely reported 10 and the temptation to use it to justify their activities may be irresistible to
Physician educators have been charged with incorporating systems-based approaches into medical education and residency training to help future physicians understand how their ability to provide high-quality health care depends on other individual and organizational stakeholders with whom and, in some cases, for whom they work. In part, this also requires that physicians accept that they have responsibilities to various system stakeholders. These changes are controversial because some fear they might distract physicians from their primary ethical obligation to their patients. However, systems theories and their applications in organizational management and business ethics support the notions that individuals can maintain primary professional ethical obligations while working within complex systems and that organizational systems can be constructed to support individual professional practice. If physicians are to commit to working within and, ultimately, improving systems of care as part of their ethical practice of medicine, then they will need a new mental model. Leading thinkers have used various models of systems and have highlighted different aspects of systems theories in describing organizations, groups of organizations, and organizational processes. This essay draws from these models some basic concepts and elements and introduces a simple but comprehensive mental model of systems for physicians. If it is used with professionalism and moral imagination, physicians might have a tool that they can use to understand, work with, and, ultimately, improve the systems of care that they rely on in their practice of medicine and that critically affect the welfare of their patients.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.