Hospital Ethics Committees: A Survey in Upstate New York

Summary This survey describes in detail ethics committees (ECs) at acute care hospitals in Upstate New York. It finds that in just two years (1984 and 1985), following the Baby Doe controversy and the Report of the President’s Commission, 40% of urban ECs and 37% of university ECs were formed. One half of rural ECs formed in 1992–1995, following the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement of access to ethics consultation. Generally, ECs are committees of the powerful within the hospital; the administration or the medical staff is the organizational parent of 73% of ECs. These groups appoint 80% of EC chairs and 79% of members; they constitute 45% of the membership. Most EC members (81%) lack even rudimentary formal training in bioethics, yet only 18% of ECs consider member education a major role. Many ECs are rather inactive: 53% meet less than every other month and 61% have fewer than six case consultations in the prior year. On the basis of this survey’s findings, suggestions are offered to improve the credibility of these ubiquitous committees as stewards of bioethics, rather than of the powerful within the hospital.     

Ethics Committees in the Rural Midwest: Exploring the Impact of HIPAA

ABSTRACT:  Context: Confidentiality of personal health information is an ethical principle and a legislated mandate; however, the impact of the Health Insurance Portability and Accountability Act (HIPAA) on ethics committees ethics committees is limited. Purpose: This study investigates the prevalence, activity, and composition of ethics committees located in rural central and southern Illinois. Additionally, the impact of the HIPAA Officer serving on the committee is reported. Methods: Surveys were mailed to the "Administrator or Ethics Committee Chairperson" at rural Illinois hospitals and skilled care facilities. Survey items included committee composition and perception of HIPAA-related involvement. Findings: Over one third (36.7%) of the facilities reported having formal ethics committees. Hospitals were more likely (79.3%) to have ethics committees than skilled nursing facilities (20.7%). Ethics committee members usually include an administrator, nurse, and physician. The smaller the facility (based on number of beds), the more likely it was to have a HIPAA Officer on the committee. Committees with a HIPAA Officer were more likely to be involved in monitoring and/or remediation of HIPAA privacy and security violations. Most respondents, however, did not feel the committee should be involved in these issues. Conclusions: Although the sample size is too small to generalize, HIPAA does seem to have an effect on the issues discussed by ethics committees. Furthermore, ethics committees that include a HIPAA Officer in the membership report increased committee involvement in HIPAA related issues .     

The Impact of Committee Caracteristics on the Success of Healthcare Ethics Committees

Despite the increase in number and importance of healthcare ethics committees (HECs), little is known about how successful HECs are and what characteristics contribute to their success. The current study attempted: (1) to examine the effect of respondent backgrounds on the self-reported success and characteristics of HECs, (2) to describe the current success status of HECs, and (3) to explore how committee characteristics are related with the success. Questionnaires on characteristics of respondents and committees as well as the rating of success were distributed to 962 acute care hospitals with 300 beds or more across the United States in the calendar year 2000. A total number of 294 chairpersons and 223 members from 334 ethics committees responded to the survey, yielding a 35% response rate. Statistical analyses on the survey data found that the length of services on committees (seniority) and the size of committees were significant contributors to the perceived success of committees. The significant association of seniority suggests that future studies should control for the effect of seniority, possibly using multivariate modeling methods. The more success perceived by large committees indicates a need for small committees to increase the size of their committees so that they can expand their expertise to resolve the wide variety of current issues.     

Maryland hospitals get plan for creating ethics committees

The Maryland Hospital Association's Advisory Committee on Medical Ethics, charged to assist member hospitals in forming ethics committees, focused on four concerns: study and development, physician support, patient/family participation, and potential issues. The committee recommended as a first step in establishing an ethics committee the creation of a study group. It warned hospitals not to expect a fully operational ethics committee immediately. A start-up period, according to the committee, should be used to develop a process for handling ethical questions and for educating the hospital community about the committee's role. To promote the best possible decision making, the hospital ethics committee should function as a support unit, for physicians as well as for patients, families, and hospital personnel. Clearly stated policies will provide a basis for appropriate intervention and help gain physician cooperation, the committee said. Such policies should encourage ethics committees to anticipate problems and to review decisions already made. While recognizing the need to involve patients' families in decision making, the advisory group agreed that the question of their presence at committee meetings should be addressed by each institution. In cases of controversial treatment or disagreement about the course of treatment, patient/family access to the committee should be clearly defined. The advisory committee suggested that each institution prepare its own list of topics that an ethics committee might consider. It also prepared a "model statement" of an ethics committee's purposes, membership, and procedures.     

Evaluation of Viewpoints of Health Care Professionals on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas Based on Practice Environment

We sought to evaluate whether health care professionals’ viewpoints differed on the role of ethics committees and hospitals in the resolution of clinical ethical dilemmas based on practice location. We conducted a survey study from December 21, 2013 to March 15, 2014 of health care professionals at six hospitals (one tertiary care academic medical center, three large community hospitals and two small community hospitals). The survey consisted of eight clinical ethics cases followed by statements on whether there was a role for the ethics committee or hospital in their resolution, what that role might be and case specific queries. Respondents used a 5-point Likert scale to express their degree of agreement with the premises posed. We used the ANOVA test to evaluate whether respondent views significantly varied based on practice location. 240 health care professionals (108—tertiary care center, 92—large community hospitals, 40—small community hospitals) completed the survey (response rate: 63.6 %). Only three individual queries of 32 showed any significant response variations across practice locations. Overall, viewpoints did not vary across practice locations within question categories on whether the ethics committee or hospital had a role in case resolution, what that role might be and case specific queries. In this multicenter survey study, the viewpoints of health care professionals on the role of ethics committees or hospitals in the resolution of clinical ethics cases varied little based on practice location.     

The impact of state maternal mortality study committees on maternal deaths in the United States.

State maternal mortality study committees have been widely credited with playing a prominent role in reducing maternal death rates in the United States. To evaluate this hypothesis, we compared the rates of decline in maternal mortality ratios by decades from 1938-40 to 1968-70 for states with such committees to those without. Ratios were calculated from published vital statistics of the United States, and committee initiation dates were obtained from a previous survey. States with committees and those without had nearly equal declines during the first decade; however, states with committees had smaller declines during the latter two decades. Although these committees may have been an important factor in the decline in maternal mortality in the United States, vital statistics data do not document larger declines for states with committees.     

Clinicians’ evaluation of clinical ethics consultations in Norway: a qualitative study

Clinical ethics committees have existed in Norway since 1996. By now all hospital trusts have one. An evaluation of these committees’ work was started in 2004. This paper presents results from an interview study of eight clinicians who evaluated six committees’ deliberations on 10 clinical cases. The study indicates that the clinicians found the clinical ethics consultations useful and worth while doing. However, a systematic approach to case consultations is vital. Procedures and mandate of the committees should be known to clinicians in advance to ensure that they know what to expect. Equally important is bringing all relevant facts, medical as well as psychosocial, into the discussion. A written report from the deliberation is also important for the committees to be taken seriously by the clinicians. This study indicates that the clinicians want to be included in the deliberation, and not only in the preparation or follow-up. Obstacles for referring a case to the committee are the medical culture’s conflict aversion and its anxiety of being judged by outsiders. The committees were described as a court by some of the clinicians. This is a challenge for the committees in their attempt to balance support and critique in their consultation services.     

Economic Impact of the Critical Access Hospital Program on Kentucky's Communities

Context: In 1997, the Medicare Rural Hospital Flexibility Grant Program created the Critical Access Hospital (CAH) Program as a response to the financial distress of rural hospitals. It was believed that this program would reduce the rate of rural hospital closures and improve access to health care services in rural communities. Objective: The objective of this paper is to analyze the economic impact of the CAH Program on Kentucky's communities. Methods: Both an economic input‐output model and a quasi‐experimental control group method are used in this research paper. While the analysis using the input‐output model uses data from the year 2006, the analysis using the quasi‐experimental control group method uses data from 1989 to 2006. Conclusion: The results indicate that the rural counties where a CAH was adopted did appear to benefit in economic terms relative to those that did not have a CAH.     

Impact of Conversion to Critical Access Hospital Status for Oklahoma''s Rural Hospitals

CONTEXT: The Medicare Rural Hospital Flexibility Grant Program established a new hospital category, the Critical Access Hospital, designed to provide financial stability to small rural hospitals that were losing money after changes in the Prospective Payment System implemented by Medicare. PURPOSE: This article describes the impact of conversion to Critical Access Hospital (CAH) status for 15 small rural hospitals in Oklahoma. Objectives of the study were to identify how conversion to CAH affected hospital utilization and finances for the first year after conversion. METHODS: A telephone survey was used to collect information from hospital administrators. Fifteen of 16 eligible hospitals participated in the study. FINDINGS: In general, services and patient census declined slightly with conversion to CAH. All 15 hospitals had reported losses prior to conversion, totaling $6,985,033. Ten hospitals reported losses after conversion. After converting to CAH status, the hospitals reported total losses of $3,094,547. The hospitals had a net change of $4,293,040. CONCLUSIONS: Most of the 15 study hospitals greatly improved their financial situation in the first year after conversion to CAH status, but in aggregate still operated at a loss.     

Today's ethics committees face varied issues. A CHA survey reveals committees' functions, authority, and structure

In a survey of Catholic Health Association member hospitals, 92 percent indicated they have formal ethics committees at their institutions. Sixty-two percent said their ethics committees were formed between 1983 and 1989. The survey found that current ethics committees are still committed to their traditional roles--education, policy development, and case review--but the education is directed to more diverse audiences than in the past. Support for medical and nursing staffs may be emerging as another possible function of ethics committees. The issues that precipitated the formation of institutional ethics committees have become more complex. In particular, questions involving the appropriate use of technology, the renewed awareness of patients' rights, changing relationships among healthcare providers, and conflicting social values have continued to require the intervention of ethics committees. However, the frequency with which respondents said their committees provide case consultations seems lower than it should be if committees were used to their full advantage. The institutional ethics committee can play a part in enlarging the current healthcare reform debate and promoting moral values. It can address such important questions as, Should the well-being of individuals take precedence over the well-being of communities?     

上海市医院伦理委员会伦理审核工作现状分析

对上海市33所公立医院进行了涉及人体生物医学研究的伦理审核状况的调查，结果显示，绝大多数医院伦理委员会均设有初始审核、快速审核与不良事件审核的相应操作规程和要求，但跟踪审核和不良事件审核需进一步加强，上海市医院伦理委员会的伦理审核程序需进一步统一。     

Health Care in Canada: Lessons for the United States

This paper considers various aspects of the Canadian health care system and the implications for the improved delivery of rural health care in the United States. The major aspects examined are access to care, rural hospitals, and rural physicians. A search of the pertinent literature revealed a large amount of information concerning rural physicians in Canada, but less that dealt directly with rural hospitals and access to health care in rural areas. Universal access is the cornerstone of the Canadian health care system, which is operated by each province under certain mandates of the federal government, with both providing funding for the system. The diffusion of medical technology has been slower in Canada than in the United States, which is perceived by some as a major success of the system. Little distinction is made between rural and urban hospitals in Canada, with all hospitals funded by annual global budgets from the province, rather than by direct payment for each service provided. Funding for capital items must be requested separately. This method of reimbursement allows better planning in meeting the needs of each community. Physicians in Canada are mostly private practitioners who are reimbursed by fee for service. As in the United States, there has been difficulty in attracting physicians to rural areas. However, all but one province have incentive programs to encourage physicians to practice in underserved rural areas, with some having disincentives for those locating in overserved areas. Overall, the Canadian health care system has chosen to control costs by focusing on the provider rather than the consumer and appears to be more successful in providing access to health care in rural areas of the country.     

Trust in early phase research: therapeutic optimism and protective pessimism

Bioethicists have long been concerned that seriously ill patients entering early phase (‘phase I’) treatment trials are motivated by therapeutic benefit even though the likelihood of benefit is low. In spite of these concerns, consent forms for phase I studies involving seriously ill patients generally employ indeterminate benefit statements rather than unambiguous statements of unlikely benefit. This seeming mismatch between attitudes and actions suggests a need to better understand research ethics committee members’ attitudes toward communication of potential benefits and risks of early phase studies to potential subjects. We surveyed the members of two U.S. research ethics committees using a phase I gene transfer study scenario, and compared the results to a previous survey of potential subjects’ perceptions and attitudes toward benefit and risk for the same protocol. The results show that there is indeed a gap between the subjects’ perceptions and the committee members’ views on what is appropriate to be communicated to research subjects. This discrepancy is the product of both the commonly assumed optimism of the subjects and to a “protective pessimism” of the research ethics committee members. We discuss this discrepancy using “frameworks of trust” and demonstrate the need to incorporate these frameworks into the existing model of informed consent.

Ethics committees in Japanese medical schools

The present features and functions of ethics committees in 80 Japanese medical schools were surveyed by employing questionnaires. Seventy-nine schools had already established committees on each campus (however, the ethics committee at Kitasato Medical University was formally established after the completion of this survey). The major role of Japanese ethics committees may be said roughly to correspond to that of Institutional Review Boards (IRB) in the U.S., although ethics committees have other functions as well. Among the ethics committees' many problems, two significant weaknesses should be underscored. The first is the inappropriate composition of the membership of the committees: more non-campus members, younger professionals, and women should be invited to participate. The second concern is the committees' essentially closed review process: this process has not been adequately open to the public even in cases in which the issue of the patient's confidentiality does not arise. However, several schools are now preparing to open their meetings to non-members and this policy should improve the present situation. It is fortunate, however, that the ethics committees in Japan's medical schools were established by members from each campus and not as a response to national directives or legislation.     

A survey of New Jersey hospital ethics committees

A mail survey in 1988 of all 108 hospitals in New Jersey, and telephone follow-up in 1990, investigated the extent and structure of ethics committees with attention to the distinctions between prognosis, infant care review committees (ICRC) and general ethics committees (HECs). It disclosed that as of August, 1990, 74 hospitals had prognosis committees, 16 had ICRCs, and 64 had HECs. All types of committees tend to cluster in teaching hospitals and in hospitals with 200-500 beds. HECs average 13 members which include 4-5 physicians, 2-3 nurses, administrators and clergy (1-2 each), and fewer than one each for any other single profession. The primary purpose of HECS is to develop hospital ethics policy (96%), followed by educating hospital staff (80%), and providing counsel and support to physicians (67%). Case review with recommendation is provided by 54% of the HECs and 21% are involved in confirmation of prognosis.     

The Medicare Critical Access Hospital Program: The First Year

The Medicare Critical Access Hospital (CAH) program, part of the Balanced Budget Act of 1997, is a nationwide limited service hospital program. Structured interviews were conducted in August and September 1998 with key people in state offices of rural health, state hospital associations, departments of health or departments of facility licensing in all 50 states to assess their progress in the development of the CAH program. The majority of states expressed interest in the CAH program. Twenty-one states were moving formally toward involvement in the program. States that had developed or were in the process of developing a state plan estimated that between 183 to 227 hospitals would convert to CAHs in the next one to two years. States that were the most successful with plan development appeared to be states that participated in the Essential Access Community Hospital/Rural Primary Care Hospital program, states where there was dialogue about the possibility of a limited service hospital program and states with widespread support in the state. A pressing need for most states is for reliable fiscal consulting or analysis that could be applied to individual hospitals that are considering conversion to CAHs. The CAH program shows promise for successful implementation based on its early results.     

Future financial viability of rural hospitals

Policymakers are concerned that some rural hospitals have suffered significant losses under the Balanced Budget Act (BBA) of 1997 and that access to inpatient and emergency care may be at risk. This article projects that the median total profit margin for rural hospitals will fall from 4 percent in 1997 to between 2.5 and 3.7 percent after the BBA, Balanced Budget Refinement Act (BBRA) of 1999, and Benefits Improvement and Protection Act (BIPA) of 2000 are fully implemented in 2004. The Critical Access Hospital (CAH) Program is expected to prevent reductions in inpatient and outpatient prospective payments from causing an increase in rural hospital closures.     

Examining the relationship between social media engagement and hospital revenue

Abstract

Effective use of social media by hospitals has the potential to improve hospitals’ financial performance by facilitating customer service and providing hospitals with a low-cost marketing platform. This cross-sectional study explored the relationship between hospital Facebook engagement and patient revenue in a simple random sample of United States short-term acute care hospitals. There was a positive relationship between Facebook engagement and hospital patient revenue for rural hospitals, but not for urban hospitals. Additional research is needed to identify the mechanisms through which hospitals’ social media presence influences consumer health purchasing behavior and profitability.     

The NJ SEED project: evaluation of an innovative initiative for ethics training in nursing homes

OBJECTIVES: This article reports the results of an evaluation of the New Jersey Stein Ethics Education and Development (NJ SEED) project--a statewide initiative to create, organize and educate a statewide network of regional long-term care ethics committees. The main focus of the evaluation was to measure utilization of the committees, describe how facilities have benefited from the project, and identify potential barriers to the use of this resource. METHODS: Based on administrative records from the NJ SEED project, 225 facilities were identified and asked to complete a facility survey. Ninety-three surveys were received, resulting in a 41% response rate. An additional survey of the regional ethics committees (RECs), as well as several focus groups and individual interviews were conducted to supplement the survey data. RESULTS: Fifty-eight percent of the facility respondents reported current participation in an NJ regional ethics committee. About one third (30%) of participating facilities had requested a formal case consultation (on at least one occasion) on behalf of a resident, but two thirds had consulted with their RECs on a more informal basis. Facilities that reported participating in the REC Network were more likely to have formally written policies than nonparticipants. CONCLUSIONS: Many NJ nursing homes find the statewide REC Network to be an important resource; however continued efforts need to be expended for recruiting and training facilities that are not taking full advantage of this important source of peer support and professional expertise.