<p> IntegratedEthics™ Improvement Forum Call ECC Orientation December 12, 2016</p><p>Slide 1 - Welcome to Ethics Consultation Coordinators This is Marilyn Mitchell. I am the IntegratedEthics Manager for Ethics Consultation at the National Center for Ethics in Health Care and I will be moderating today’s IE Ethics Consultation Improvement Forum call. Thank you for joining us today. Our topic today is: Ethics Consultation Coordinator Orientation. Some of my responsibilities are to help ethics consultants and Ethics Consultation Coordinators (ECCs) in the field as they begin to use ECWeb and to encourage them to incorporate the CASES approach into their ethics consultation practices. My responsibilities also include assisting ECCs in understanding the expectations of their role as defined by VHA Handbook 1004.06.</p><p>If you did not receive a reminder email for this EC Improvement Forum call, it is possible you are not signed up for the IE mailing list. You can do so easily by going to the National Center’s website and under the Integrated Ethics portion of the website you will find it. The link will be available in the minutes: http://vaww.ethics.va.gov/integratedethics/regindex.asp The call schedule and summary notes are posted on the IntegratedEthics website at: http://vaww.ethics.va.gov/integratedethics/TA.asp</p><p>Before I continue I want to mention that other staff from the Ethics Center typically join the call and you may be hearing from them. Presentation shown on the call: </p><p>Slide 2 – Joining This Meeting This meeting is a multimedia presentation requiring both audio and visual access. Audio will be available through VANTS: 800-767-1750 Access: 76479# and Online Meeting Visuals will be accessed through the Lync online meeting: Join online meeting Please call the usual VANTS line AND join the Lync online meeting. If you are having technical difficulties, please contact your local IT department to assist you.</p><p>Ground Rules – I need to briefly review the overall ground rules for these calls: PLEASE do not put the call on hold. We ask that when you speak, you please begin by telling us your name, location and title so we can continue to get to know each other better. As you may know the Ethics Center does not audiotape these calls; instead, we provide minutes. In the field some VHA facilities are audiotaping the calls to make it possible for their colleagues to hear the full text of the discussion. As a result, this is not the venue for reporting </p><p>1 violations, talking about individual case information, or disclosing identifiable patient information. </p><p>Slide 3 To begin, how long have you been doing ethics consultation? For some of you, it appears you’ve been doing ethics consultation for more than five years. A few of you are just beginning to do ethics consultation.</p><p>Slide 4 How long have you been in your role as Ethics Consultation Coordinator? Most of you are very new to the role. Welcome and thank you for joining the call today.</p><p>Slide 5 – Internet vs. Intranet www vs. vaww You all may be aware that there is a VA Internet and Intranet. This is very important because not all content for IE is available on the Internet…although as we revise our sites in response to VA requirements, they will begin to look very similar. So allow me to show the difference between the Internet (www version) and the Intranet (vaww version). The Intranet is the VA’s Internet behind their firewall and is only accessible to VA employees. It is important that you use the Intranet as opposed to the Internet. You will know that you are on the Intranet when you see the word “Intranet” at the top of the page. I have a red arrow pointing to the word Intranet. Another important way to know that you are on the VA Intranet is that you will be able to access ECWeb, our online EC database. There are some items only available on the Intranet and I will be sure to point them out if I refer to them.</p><p>Slide 6 Here is the link to the main page for the National Center for Ethics in Health Care. Please take a look at the home page which makes the point that ethics influences the quality of care delivered. It also lists some links for places to refer issues that are not appropriate for ethics consultations. National Center for Ethics in Health Care and IE Website Allow me to show you a few things about this page. There is a bar on the left that has links to many resources. I’d like to take you to the next page on our brief website tour – the IntegratedEthics Overview page. On the IE Overview page, you’ll see there are additional topic bars that are links, such as Program Management, Ethics Consultation and Preventive Ethics.</p><p>Slide 9 As the ECC, it is important that you understand the IE program. Included is a link to the IntegratedEthics Overview page where you will find a variety of resources, including a ten minute video about IntegratedEthics. http://vaww.ethics.va.gov/integratedethics/index.asp Please make sure you know your VISN POC, your VISN IE Senior Lead, Facility IE Council, your Facility Director, your Ethical Leadership Coordinator, your IE Program Officer and your Preventive Ethics Coordinator. For additional information, read the IE Ethical Leadership primer.pdf and IE Preventive Ethics primer.pdf.</p><p>Slide 10 To begin your role as an IE ECC, please look through the ECC Hand-Off Guide http://vaww.ethics.va.gov/ETHICS/docs/integratedethics/ECC_hand-off_Guide_120716.doc</p><p>2 because it covers training, including website addresses and materials along with ECWeb. It is recently updated so all of the information is current. It also covers transitioning the Facility EC Program from one ECC to another. For a detailed explanation of the role of ECC, please see the VHA Handbook 1004.06. This is your most authoritative source for understanding your role. http://vaww.va.gov/vhapublications/VHA Handbook 1004.06.</p><p>Slide 9 – Managing the Ethics Consultation Service at Your Facility – You are in a position to role model the CASES approach, we will review the CASES approach in a minute. In your new role, one of the most important things you’ll be doing is being a mentor to any less experienced consultants. We all have had mentors, the more generous they are with their knowledge, the more we have benefitted. Be a mentor that changes lives, a mentor that sees the potential in your ethics consultants for their growth, for their increasing involvement in ethics and for their potential to bring a unique perspective to the care of Veterans. Another role you’ll want to play is being a resource by knowing where to find the appropriate ethics knowledge. You want to be able to direct others to an article you read or a book chapter. By doing these things, you will become an inspiration to those interested in IE. Talk about the importance of high quality ethics and its influence on the delivery of care. Bring information about the IE Program to parts of your facility that may not be utilizing the service as needed; whether that means doing a lunch & learn on a dialysis unit or a mental health department or perhaps giving a talk about the CASES approach to medical or nursing students. Being a mentor, a resource for ethics knowledge and an inspiration will help you to grow your ECS.</p><p>Slide 10 – Ethics Consultation Primer – The document called Ethics Consultation: Responding to Ethics Questions in Health Care is the document that you will repeatedly visit to help establish and maintain your EC service. We call it the primer. http://vaww.ethics.va.gov/ETHICS/docs/integratedethics/ec_primer_2nd_ed_080515.pdf All ethics consultants need to read it before they begin doing ethics consultation.</p><p>Slide 11 – CASES – The CASES approach is the process recommended for use with every request for ethics consultation. This is a brief review of the CASES approach. • C – Clarify – Characterize the type of request – Obtain preliminary information – Establish realistic expectations – Formulate the ethics question • A – Assemble – Consider the types of information needed – Identify the appropriate sources of information – Gather info systematically – Summarize the case and the ethics question • S – Synthesize – Determine whether a formal meeting is necessary – Engage in ethical analysis – Identify the appropriate decision maker – Facilitate moral deliberation</p><p>3 • E – Explain – Communicate the synthesis – Provide additional resources – Document in the health record & ECWeb • S – Support – Follow up with participants – Evaluate the consultation – Adjust the consultation process – Identify underlying systems issues When you use the CASES approach to ethics consultation, you’re using a systematic, well developed approach that coordinates with how to obtain results that meet the needs of those that request ethics consultation. The CASES approach is aligned with ECWeb, so each step is documented in a consistent way.</p><p>Slide 12 – ECC Responsibilities – One of the responsibilities of the ECC includes ensuring access to the ethics consultation service during normal working hours. You are likely to need to enlist ethics consultants on your service for coverage if you are not available to speak to a requester. You’ll want to make sure that all ethics consultants complete the following:  Read the Ethics Consultation Primer: http://vaww.ethics.va.gov/ETHICS/docs/integratedethics/ec_primer_2nd_ed.pdf  Complete the two part ethics consultation video course http://www.ethics.va.gov/Ethics_Consultation_Part1.asx http://www.ethics.va.gov/Ethics_Consultation_Part2.asx  View the ECWeb online learning module: http://www.ethics.va.gov/ecweb/default.htm Included in the summary is a link to a one page New Ethics Consultant Guide which is an outline of what new consultants will need to complete. http://vaww.ethics.va.gov/ETHICS/docs/integratedethics/new_ethics_consultants_guide.pdf</p><p>Slide 13 - ECC Responsibilities – Completing the EC Proficiency Assessment Tool is done annually in order to assess the knowledge and skill level of your ethics consultants. Everyone on your EC service needs to complete this self-assessment which we call the ECPAT. It takes about 15 – 20 minutes to complete. This tool helps to establish the quality of your EC service by finding areas for improvement. Items were taken from The American Society for Bioethics and Humanities’ (ASBH) core competencies and measures EC skills and knowledge. The consultant is asked to rate themselves as novice, basic or advanced in various areas. The link below is for an ECPAT that can be printed out. http://vaww.ethics.va.gov/ETHICS/docs/integratedethics/ec_pat_12232013.docx The most useful tool for gathering your EC proficiency for the entire service information, though, is the Electronic EC PAT and the link is below: http://vaww.infoshare.va.gov/sites/IntegratedEthics/ElectronicVersion.ECPAT.xlsx Please make sure if you use the Electronic version that you save it on your own computer and close it since it is on the SharePoint site and others cannot use it while you have it locked. The Electronic ECPAT will automatically graph your entire service’s results in knowledge and skills categories. The completed proficiency assessments are given to the ECC. The ECC’s job is to aggregate all the information from each assessment into the EC Service Proficiency Assessment Tool (ECSPAT) that summarizes the skill and knowledge level of the ethics consultants. Please </p><p>4 note: only the items with an * are compiled for the ECSPAT. The others are good for you to know as an ECC so you can have a greater understanding of the proficiency of your individual consultants and can then determine who is the appropriate consultant for particular consults. It will also help you to appropriately mentor those members of your team with novice proficiency in a variety of areas and for creating individual professional development plans.</p><p>Slide 14 – FY17 IE Program Reporting Metrics and Technical Manual – Located under the IntegratedEthics heading is the link to the IE Program Metrics. The link to the technical manual is below: http://vaww.ethics.va.gov/docs/integratedethics/FY17_IE_program_reporting_metrics_and_tech nical_manual.pdf The focus of IE Program Achievement metrics have begun to focus more on improving the quality of the ethics consultation process. We recognize that improving health care quality for our Veterans involves delivering high quality ethics consultation. One way to measure ethics consultation quality is to review the documentation. We did review ethics consultation documentation in FY15 when we looked at the ethics questions of two case consult records. We spent FY15 really working to bring everyone’s attention to how formulating the ethics question to include the values perspectives of each party helps to focus the consult process. For FY17, we will be going a step further. We will want to see one closed case consult record so we can review the ethics question along with the recommendations made. We’ll be looking to see that those recommendations address the concerns raised in the ethics question. We’ll be targeting our Improvement Forum calls to assist in how to develop clear, practical recommendations that address the ethical issues.</p><p>Slide 15 – EC1 Goal – For our first goal this fiscal year we will be focusing on ethics consultation documentation. By the close of Q2 FY17, each facility will submit to NCEHC the ECWeb record number for one closed ethics case consultation. For those of you that won’t have a closed case consult record by close to the end of Q2 this year – please contact me. Achievement of EC1 will be based on documented correlation between the ethics question and the recommendations for the consult, as assessed by NCEHC. This is important because it demonstrates high quality practices in ethics consultation and works to illustrate how the final conclusions and recommendations reflect the original ethics question. If the initial case consultation does not meet the requirement, additional ECWeb consult record numbers should be submitted until the target achievement is met. That achievement target is, defined as demonstrated correlation between the recommendations and the ethics question, along with meeting the specifics regarding the ethics question and the recommendations. To meet the measure we are looking for 4 aspects. Specifically, the ethics question should: 1. clarify the ethical concern(s) (uncertainty or conflict about values) that gave rise to the consultation request; </p><p>2. identify whose values are uncertain or in conflict; and</p><p>3. identify the decision(s) or action(s) in question. </p><p>And, the recommendations in the consultation record should be ethically justifiable and responsive to the ethics question(s). </p><p>You may recall from FY15, most ethics questions did not identify the values that were uncertain or were in conflict. Our analysis for FY2017 continues that assessment. If you’d like more </p><p>5 information on formulating an ethics question, it’s good to re-read our EC Primer http://vaww.ethics.va.gov/ETHICS/docs/integratedethics/ec_primer_2nd_ed_080515.pdf or review the materials from our Ethics Consultation Beyond the Basics course, Module 2 – Formulating the Ethics Question. We will be discussing writing recommendations during this fiscal year. For the documentation, beginning in Q1 but no later than the close of Q2 FY2017 each facility will submit one ECWeb record number for a closed case consultation from FY17 that reflects a correlation between the ethics question and the consultation recommendations. Within ECWeb, the ethics question must be in the “Ethics Question” field and the recommendations must be in the “Recommendations/Plans” field. Thank you for using the proper fields – it’s time consuming to hunt through the consult record for that information. The target achievement of EC1 is based on document review by NCEHC that the submitted consult record meets the three (3) standards for the ethics question and the one (1) standard regarding the recommendations.</p><p>Slide 16 - EC1 Goal Example (Ethics Question) – Here’s an example of an ethics question along with recommendations that are ethically justifiable and responsive to the question. It may look familiar because it’s from one of our ECQAT examples. It’s sample case #1. The link to the ECQAT section of our website will be in the summary. http://vaww.ethics.va.gov/ETHICS/docs/integratedethics/sample_case_home_oxygen _040315.pdf Given that the treatment team is concerned that they should not provide oxygen to the patient for end stage COPD because the patient’s smoking could lead to harm, but the patient believes he ought to be able to get O2 and continue his life-style choice to smoke because he is dying, what decisions or actions are ethically justifiable? </p><p>Slide 17 – Recommendations – Now these are recommendations for the consult. All agreed that the home care team should continue to provide O2 therapy and should engage in ongoing periodic review of the patient’s actions to mitigate fire risk. 1. The team is ethically justified in encouraging smoking cessation for the patient as long as it is presented as a treatment option and it is not offered in a coercive manner. 2. The team should periodically assess the patient and perform rigorous safety assessments to determine if the risk to the patient or others changes. If so, they should balance the patient’s right to make choices about his behaviors and treatments with the risks to the patient or others as a result of behaviors and treatments and revise the treatment plan with the patient. </p><p>Slide 18 – EC1 Goal Example (Recommendations continued) 3. An additional safety measure would be to include, with the patient’s permission, first responders in the care decision. An attempt should be made to inform the local fire department of patient's continued smoking with O2-not as punitive measure but as an added safety measure in case of an emergency. A release of information (ROI) should be obtained from the patient and sent to ROI office for processing. The reason this example was chosen was because the recommendations specifically address the decision in question – whether to provide O2. It’s important to note, that for the requester, the recommendations may be the most practical part of the consultation process. Although we know everything you write is important to the ethics consultation process, we also know that the </p><p>6 requester may only be interested in this section. That’s one reason why you’ll want them to be clear, useful and ethically justifiable. </p><p>Slide 19– Additional Notes about EC1 – When we discussed this metric with the VISN POCs, they suggested we make sure the documentation is privileged since this is a quality improvement activity. We agreed with their suggestion and therefore this review will be kept confidential.</p><p>Slide 20 – EC2 Goal – Now let’s talk about the EC2 goal for this FY. </p><p>The requirement is that facilities will demonstrate a functioning participant feedback mechanism for ethics consultation through the use of ECWeb. They will demonstrate it by having 50% of closed FY17 ethics consultations in ECWeb documented as either “evaluated” or “no evaluation response”.  Documentation: By the close of Q4 FY17, as documented in ECWeb, 50% of closed FY17 case and non-case consultations (see note below) include either an evaluation or documentation of no evaluation response. Facilities will not need to submit documentation. NCEHC will use ECWeb to obtain evaluation data.</p><p> Target: 50% of ECWeb records of closed consultations (case and non-case) include either an evaluation or documentation of no evaluation response. NCEHC will post quarterly evaluation reports to the VISN & Facility SharePoint site so facilities may track their progress. </p><p>Slide 21 – Current Evaluation Data – FY16 – This is the evaluation data for FY16 for all facilities. We ended the year with a total of 1971 consult records. Subtracting the open consults from the total – gives us 1374 consults that have the potential to be evaluated. We can see that 325 of consults were evaluated and 116 had no evaluation response. When we add all of those together we see a total of 441. If 441 is the sum of the evaluated and the no evaluation response, out of a total of 1374, that gives us a national rate of 32%. We’d like that rate to be 50% by the end of the fiscal year. </p><p>STATUS OF CONSULTATIONS Number of records in this table: 1971</p><p>CASE NON-CASE BOTH STATUS OF CONSULTATIONS N N N % % % 519 78 597 Open 32% 22% 30% 309 124 433 Finished 19% 36% 22% 414 86 500 Pending Evaluation 25% 25% 25% 280 45 325 Evaluated 17% 13% 16% 102 14 116 No Evaluation Response 6% 4% 6%</p><p>7 1624 347 1971 TOTAL 100% 100% 100%</p><p>Slide 22 - Evaluation Calculation – Here’s an example of the way to calculate your evaluation percentage. Numerator: Consults put through the evaluation process. That is, evaluated consults plus consults with no evaluation response = e.g., 8 + 4 = 12 consults put through the evaluation process Denominator: Consults available for the evaluation process. That is, total consults minus open consults = consults available for the evaluation process e.g., 22 – 2 = 20 12 / 20 = 0.6 or 60% </p><p>Slide 23 – Setting Up an Evaluation Process – We understand that for some facilities this will be a new task and having guidance as to how to evaluate consults will be appreciated. Our ECWeb FAQ Guide does a fine job of giving step-by- step instructions. http:// vaww.ethics.va.gov/ETHICS/docs/integratedethics/ecweb_faq_06252015.docx Within the ECWeb FAQ Guide, a standard evaluation form is embedded for your use. In an effort to make requesting evaluations easier, attached in the summary is a document we use at the NCEHC and you can copy & paste into an email when requesting an evaluation. Please note, there are portions indicated where it should be personalized, especially since it has the National Center for Ethics in Health Care’s name in the message. You’ll want it to be your facility name.</p><p>Slide 24 – IE VISN & Facility SharePoint Site – This is where many IE documents may be found. The link is from the IntegratedEthics website and it will be shared in the summary notes. http://vaww.infoshare.va.gov/sites/IntegratedEthics/default.aspx</p><p>Please make sure you sign up for the IE Mailing List since that’s how you’re given permission to upload documents to this site. If you have any challenges with uploading documents, please contact me. This is where the EC Goal documentation is usually stored.</p><p>Slide 25 – Administering ECWeb – The ECC and at least one other person needs to be trained and have access to ECWeb as an Administrator of ECWeb at your facility. This is the link to ECWeb. Remember, you must be logged into the computer using your log in information to be able to access ECWeb. A link to ECWeb will be in the summary. https://vaww.ecweb.ethics.va.gov/main.cfm</p><p>Slide 26 – ECWeb Online Learning Module and FAQ Guide – On this slide you’ll see an image from the Ethics Consultation webpage with a red circle around where the ECWeb Online Learning Module link is located and above that is the link to the ECWeb Frequently Asked Questions Guide. Just to let you all know, we update the FAQ Guide regularly since there are changes made to ECWeb that we want to reflect in the guide.</p><p>8 Slide 27 – EC Pocket Card for CASES – This is the link for the CASES pocket card. You can print it out and have it laminated for new ethics consultants to carry with them. It’s a handy tool for doing a consult. Remember, ECWeb is organized along the CASES approach so if you help new consultants to use the CASES approach from the beginning, they will find it easier to do a thorough job and to document in ECWeb.</p><p>Slide 28 – Register for the IE Mailing List – This is the link to register for the IE Mailing List. You can specify that you’d like just ethics consultation information when you sign up. We send out two messages for every Improvement Forum call – one on the Wednesday before the call and one on the morning of the call as a reminder.</p><p>Slide 29 – Questions? Now I’d like to open it up for comments and questions. Please do not hesitate to speak up.</p><p>Q: My Lync doesn’t have a paperclip with the documents you mentioned. How do I get them?</p><p>A: I’ll email them to you. All the documents will also be available in the summary notes for this call. </p><p>Thank you everyone for those questions & comments. We will have a summary of the call up on the website in a short while for you to review as needed.</p><p>Slide 30 – Poll – Before you leave the call, please indicate on our anonymous poll how helpful you found this call “I found this call helpful and useful to the work I do in IntegratedEthics” </p><p>Slide 31 – Please remember, that like the rest of my New York colleagues, my door, my email, [email protected] and my phone (212-951-5477) are always open to hear from you.</p><p>The next EC Improvement Forum call will be on January 23rd, 2017 on topic of Aligning Ethics Questions with Ethics Recommendations. See you then.</p><p>Take care – and thank you for everything you do to deliver excellent care to our Veterans. </p><p>9</p>