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 Presence of Ethics Programs in Critical Access Hospitals

The purpose of this study was to assess the presence of ethics committees in rural critical access hospitals across the United States. Several studies have investigated the presence of ethics committees in rural health care facilities. The limitation of these studies is in the definition of ‘rural hospital’ and a regional or state focus. These limitations have created large variations in the study findings. In this nation-wide study we used the criteria of a critical access hospital (CAH), as defined by the Medicare Rural Hospital Flexibility Program (Flex Program, 2007), to bring consistency and clarity to the assessment of the presence of ethics committees in rural hospitals. The Flex Monitoring Team conducted a national telephone survey of 381 CAH administrators throughout the United States. The survey covered a wide variety of questions concerning hospitals’ community benefit, impact activities, and whether the hospital had a formally established an ethics committee. About 230 (60%) of the respondents indicated they had a formally established ethics committee or ethics consultation program at their CAH. The prevalence of ethics committees declined as the CAH location became increasingly rural along a rural–urban continuum. Unlike CAHs, all rural Department of Veterans Affairs Medical Centers have ethics committees. The results of this study provide an understanding of the limited presence of ethics committee in rural America and the need to consider new approaches for providing ethics assistance. A virtual ethics committee network may be the most efficient and effective way of providing rural hospitals access to a knowledgeable ethics committee or consultant.     

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.     

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.     

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.     

Ethics Committees in Croatia in the Healthcare Institutions: The First Study about their Structure and Functions, and some Reflections on the Major Issues and Problems

OBJECTIVES: In Croatia, ethics committees are legally required in all healthcare institutions by the Law on the Health Protection. This paper explores for the first time the structure and function of ethics committees in the healthcare institutions in Croatia. DESIGN: Cross-sectional survey of the healthcare institutions (excluding pharmacies and homecare institutions) to identify all ethics committees. SETTING: Croatia six years after the implementation of the Law on the Health Protection. MAIN MEASUREMENTS: Structure and function of ethic committees in the healthcare institutions. RESULTS: 46% of the healthcare institutions in Croatia (excluding pharmacies and homecare institutions) have an ethics committee; 89% of ethics committees have 5 members 3 of whom are from medical professions and 2 come from other fields; 49% of those committees stated that their main function is the analysis of research protocols. Only a small fraction of those ethics committees sent in standing orders, working guidelines or other documents that are connected with their work. CONCLUSIONS: Although there are legal provisions for ethics committees in the healthcare institutions in Croatia, there is an evidence of discrepancies between the practice and the "Law on the Health Protection," suggesting the need for revision of the law. There is a need for creating separate networks of HECs and IRBs in Croatia. In comparison with other countries, the development of ethics committees in Croatia has some similarities with other transitional societies in Europe. Additional research should be undertaken in the work of ethics committees in Croatia in order to understand committees' group dynamics, attitudes, and knowledge.     

Ethics committees in neonatal care: substantive protection or procedural diversion?

The federal government, the American Academy of Pediatrics, and the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research have all proposed the establishment of hospital ethics committees to solve decision making dilemmas in neonatal as well as other critical care areas. Annas argues that education, consultation, and policy making are inappropriate committee functions and identifies individual case adjudication as the only role uniquely suited to ethics committees. He concludes that the first priority is the development of substantive standards on which committee decisions can be based.     

Institutional Challenges for Clinical Ethics Committees

Clinical ethics committees (CECs) have been developing in many countries since the 1980s, more recently in the transitional countries in Eastern Europe. With their increasing profile they are now faced with a range of questions and challenges regarding their position within the health care organizations in which they are situated: Should CECs be independent bodies with a critical role towards institutional management, or should they be an integral part of the hospital organization? In this paper, we discuss the organizational context in which CECs function in Europe focusing on five aspects. We conclude that in Europe clinical ethics committees need to maintain a critical independence while generating acceptance of the CEC and its potential benefit to both individuals and the organization. CECs, perhaps particularly in transitional countries, must counter the charge of “alibi ethics”. CECs must define their contribution to in-house quality management in their respective health care organization, clarifying how ethical reflection on various levels serves the hospital and patient care in general. This last challenge is made more difficult by lack of consensus about appropriate quality outcomes for CECs internationally. These are daunting challenges, but the fact that CECs continue to develop suggests that we should make the effort to overcome them. We believe there is a need for further research that specifically addresses some of the institutional challenges facing CECs.     

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。     

Present status of ethics committees of the medical schools in Japan

Present features and functions of ethics committees in 80 Japanese medical schools were surveyed through inquiries to those institutes by the author. Seventy nine schools have already started their own committees in each campus by the end of 1990, and the remaining one is preparing for its start in near future. The major role of the ethics committee may be said to roughly correspond to that of the Institutional Review Boards (IRB) in the USA, although a role of the hospital ethics committee has been played in addition to its proper functions in many schools. Among many problems two major drawbacks seem necessary to be removed urgently. The first one is an inappropriate composition of the committee in the majority of schools. More members from the outside of the campus, younger generations, and female reviewers should be added to the committee. The second point is the essentially closed review systems in most schools. The process of the review has not been effectively opened to the public yet, even in case in which no privacy of the patients or volunteers appears in the discussion. Several schools are preparing for opening now and the situation will be improved gradually. It was fortunate that the ethics committees in Japanese medical schools were founded by wills and efforts of members of each campus without having any suggestions, recommendations, or orders from the national government or other officials.     

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.     

A survey of national ethics and bioethics committees

ObjectiveTo assess the current state of national ethics committees and the challenges they face.MethodsWe surveyed national ethics committees between 30 January and 21 February 2018.FindingsIn total, representatives of 87 of 146 national ethics committees (59.6%) participated. The 84 countries covered were in all World Bank income categories and all World Health Organization regions. Many national ethics committees lack resources and face challenges in several domains, like independence, funding or efficacy. Only 40.2% (35/87) of committees expressed no concerns about independence. Almost a quarter (21/87) of committees did not make any ethics recommendations to their governments in 2017, and the median number of reports, opinions or recommendations issued was only two per committee Seventy-two (82.7%) national ethics committees included a philosopher or a bioethicist.ConclusionNational ethics (or bioethics) committees provide recommendations and guidance to governments and the public, thereby ensuring that public policies are informed by ethical concerns. Although the task is seemingly straightforward, implementation reveals numerous difficulties. Particularly in times of great uncertainty, such as during the current coronavirus disease 2019 pandemic, governments would be well advised to base their actions not only on technical considerations but also on the ethical guidance provided by a national ethics committee. We found that, if the advice of national ethics committees is to matter, they must be legally mandated, independent, diverse in membership, transparent and sufficiently funded to be effective and visible.     

Determinants of hospital ethics committee success

In December 1990, an empirical study assessing hospital ethics committee (HEC) success was completed. Success was measured in terms of the number of interventions undertaken by the committees in four functional areas: education, guidelines development, prospective and retrospective case review. Some commonly quoted success determinants, such as multidisciplinarity, physician chairpersons, and a high institutional status of the chairperson were found not to foster success; the latter two, actually decreased committee success.     

Exploring the role of the ethics committee psychiatrist

Healthcare ethics committees (HEC) have emerged as institutional forums for addressing bioethical dilemmas. Psychiatrists have important roles to play on these committees. Their skills in group process assessment, mental status examination, and character assessment have diverse applications. Psychiatrists can facilitate communication within the committee and as HEC-based clinical ethics consultants. HECs must be concerned with how they arrive at ethical decisions, guarding against political influence or individual monopolization. Psychiatrists can assist these efforts as organizational consultants to HECs. The perception of psychiatrists as reflective, tolerant of ambiguity, humanizing, and approachable about ethical aspects of health care suggests they would make excellent committee leaders. Psychiatrists also have important committee roles to play as ethics educators and policy makers. More demographic data is needed to investigate psychiatrist participation on HECs. Studies of how they are perceived by their ethics committee colleagues may reveal new roles and potential pitfalls for HEC psychiatrists.     

A welcome guide for evaluating medical research involving human subjects

In 1999, the Dutch Medical Research Involving Human Subjects Act came into force. The principal aim of this Act is to provide protection for human subjects who take part in medical research. Medical research involving human subjects may only be carried out after it has been approved by a recognised medical ethics committee. A central committee (Dutch acronym: CCMO) regulates the recognition of the local medical ethics committees and monitors their performance. For some types of research the protocol has to be reviewed by the CCMO itself. These are: non-therapeutic research involving children and mentally incompetent patients and research on gene therapy, xenotransplantation and embryos. The CCMO has recently published a guide for the local medical ethics committees. It presents an excellent overview of all the legal and practical aspects of the work of medical ethics committees. The guide is highly recommended.     

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?     

Taking on organizational ethics. To do so, ethics committees must first prepare themselves

Healthcare ethics committees which have focused almost entirely on clinical ethics, now need to prepare to deal with organizational ethics, a field that is attracting increasing attention. As they did with clinical ethics, ethics committees members must educate themselves in the demands of the newer field. As before, they must respect the perspectives of the actual decision makers while maintaining an independent framework for analyzing the issues at stake. They must ensure that management is properly represented on the committee if they need guidance from a professional ethicist they should seek one with a strong background in business ethics and social justice. Healthcare organizations are likely to need help with a wide range of ethical issues involving patient services (rationing of resources, for example), business and service plans (mergers and joint ventures, for example), business and professional integrity (conflicts of interest, for example), employee rights and responsibilities (downsizing, for example), and the organization's role in in the community (advocacy and lobbying, for example). To be helpful to the organization, the ethics committee must be prepared to say when cost factors trump other considerations and when they do not. An ethics committee will often be asked to give advice on specific occasions-a proposed new policy, for instance. The most important part of its response is its analysis of the issue. Finally, an ethics committee should view its organization as part of the larger social context.