The use of an online comment system in clinical ethics consultation

Abstract

Background Although a mechanism for resolving ethical issues in patient care is required for accreditation of American hospitals, there are no formal qualifications for providing clinical ethics consultation (CEC), and there remains great variability in the composition of ethics committees and consult services. Consequently, the quality of CEC also varies depending on the qualifications of those performing CEC services and the format of CEC utilized at an institution. Our institution implemented an online CEC comment system to build upon existing practices to promote consistency and broad consensus in CEC services and enable quality assurance. Methods This qualitative study explored the use of an online comment system in ethics consultation and its impact on consensus building and quality assurance. All adult ethics consultations recorded between January 2011 and May 2015 (n=159) were analyzed for themes using both open and directed coding methods. Results We found that comments broadly reflected three categories: expressions of approval/agreement (87% of consults), comments about the case (89%), and comments about the written record (72%). More than one-third of consults included responses to other comments (37%). The most common types of “comments about the case” included requests for additional information (36%), recommendations for additional services (21%), and references to formal policies/standards (28%). Comments often spanned multiple categories and themes. Comments about the written record emphasized accessibility, clarity, and specificity in ethics consultation communication. Conclusions We find the online system allows for broad committee participation in consultations and helps improve the quality of CEC provided by allowing for substantive discussion and consensus building. Further, we find the use of an online comment system and subsequent records can serve as an educational tool for students, trainees, and ethics committee members.

A systematic review and meta-synthesis of policy intervention characteristics that influence the implementation of government-directed policy in the hospital setting: implications for infection prevention and control

“…In most studies, however, consideration of policy implementation was not reported at the point of policy development but was actively performed separate to the directing government body. In some cases, this was undertaken by a coordinating centre or other health system entity or by hospital clinicians themselves as part of the policy implementation and evaluation process (Canaway et al, 2017;Hauschildt et al, 2017;Iorio, 2015;Ketko et al, 2015;Kozhimannil et al, 2013;Nisly et al, 2013;Rejtar et al, 2017;Richards et al, 2008;Shiloach et al, 2010;Smith et al, 2009;Stone et al, 2015;Yelland et al, 2017).…”

“…Planning and resourcing Planning for implementation and resourcing of implementation activity was included in policy intervention Canaway et al, 2017;Deasy et al, 2016;Dharampal et al, 2016;Fassl et al, 2012;Hauschildt et al, 2017;Heitmann et al, 2017;Iorio, 2015;Jorgensen et al, 2010;Ketko et al, 2015;Kodal et al, 2012;Kozhimannil et al, 2013;Lambert et al, 2015;Lanese, 2016;Martínez et al, 2009;McClain et al, 2017;Morrow et al, 2012;Nisly et al, 2013;Rejtar et al, 2017;Richards et al, 2008;Russ et al, 2015;Shiloach et al, 2010;Smith et al, 2009;Stone et al, 2015;…”

“…In some cases, policy-related interventions were performed by external government entities or networks, such as professional colleges or funding bodies (Canaway et al, 2017;Deasy et al, 2016;Dharampal et al, 2016;Dumartin et al, 2011;Fanelli et al, 2017;Heitmann et al, 2017;Jorgensen et al, 2010;Ju et al, 2015;Lambert et al, 2015;Martínez et al, 2009;McClain et al, 2017;Molina et al, 2016;Morrow et al, 2012;Shiloach et al, 2010;Weeks et al, 2014). In other policy implementation examples, hospital clinicians and staff developed interventions internally to link policy directives and requirements with 'real-life' application often in the form of official policies or procedures (Childs et al, 2012;Coleman et al, 2007;Gasparini et al, 2015;Hauschildt et al, 2017;Iorio, 2015;Iorio et al, 2016;Ketko et al, 2015;Nisly et al, 2013;Padula et al, 2015;Smith and Metzger, 2011;Wiig et al, 2013;Yelland et al, 2017;Yu et al, 2017), with these tools often endeavouring to take ambiguous or generalised policy content and translating or contextualising information into clearer, more actionable instructions.…”

“…When new processes or tools were developed this often required the allocation of additional resources and, in some cases, the establishment of new roles to directly support clinical practice changes (Altman, 2012;Iorio, 2015;Iorio et al, 2016;Kahin et al, 2017;Kodal et al, 2012;Kurtzman et al, 2011;Lanese, 2016;Morrow et al, 2012;Padula et al, 2015;Purvis et al, 2017;Resar et al, 2011;Wiig et al, 2013;Yu et al, 2017). Other examples of new internal infrastructure included the introduction of information technology and decision support tools, such as electronic health record alerts or clinical decision support tools (Amland et al, 2015;Barbash et al, 2017;Calikoglu et al, 2012;Hauschildt et al, 2017;Hosford, 2008;Lambert et al, 2015;Lombarts et al, 2009;McClain et al, 2017;Nisly et al, 2013;Padula et al, 2015;Shiloach et al, 2010;Smith and Metzger, 2011).…”

“…Lastly, in policy interventions supported by infrastructure, this infrastructure often enabled processes for evaluation and performance measurement to be built in (Altman, 2012;Dumartin et al, 2011;Heitmann et al, 2017;Kahin et al, 2017;Lanese, 2016;McClain et al, 2017;McHugh et al, 2011;Russ et al, 2015;Shiloach et al, 2010;Yu et al, 2017). In some circumstances, this enabled the policy intervention to be piloted or adapted accordingly dependant on contextual needs (Hauschildt et al, 2017;Ketko et al, 2015;Morrow et al, 2012;Rejtar et al, 2017;Richards et al, 2008;Som, 2007;Wald et al, 2012;Yelland et al, 2017). Interestingly, policy interventions which were supported by external infrastructure such as corporate entities or networks often described collaboration and sharing of resources across organisations, providing a network for communication, intervention testing and scalability across differing contexts (Jorgensen et al, 2010;Ju et al, 2015;Kozhimannil et al, 2013;Marsteller et al, 2014;McClain et al, 2017;Smith et al, 2009;Stone et al, 2015;Yu et al, 2017).…”