Angel Petropanagos, Paula Chidwick, and Jill Oliver explain how clinical ethics can respond to emerging challenges in our health system by utilizing quality improvement methodologies and change management concepts.  

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At William Osler Health System, our Ethics Quality Improvement Lab is committed to improving quality health care, where quality means safe, effective, person-centred, efficient, timely, and equitable care. We engage in core ethics activities such as consultation, research, education, organizational ethics and policy development and also an innovative strategy called Ethics Quality Improvement (EQI). EQI supports an upstream, patient centred, and systematic response to emerging challenges in health care around integration and increased demands on resources. In general, it identifies and aims to prevent common consent-related errors and other recurring ethical issues that can negatively impact both individual patients and the health system.

For over a decade, we have designed and implemented award-winning projects such as the Checklist to meet Ethical and Legal Obligations (ChELO) Project, which aims to ensure decision making is patient-centred by identifying the correct substitute decision-maker when the patient is not capable, asking about advance care planning and identifying wishes, values and beliefs of the patient; the Prevention of Error-Based Transfers (PoET) Project which aims to reduce consent-related errors in long-term care homes and transfers to hospital that can follow; and the Alternative Level of Care (ALC) Project which aims to support smooth transitions from the hospital by encouraging early discussions with patients about their wishes and needs after their acute issues are resolved.

In order to spread and scale the EQI Projects we had to think differently about our approach to clinical ethics in the organizations we support and work in. For this, we rely on quality improvement methodologies and change management concepts to create changes that promote both person-centred decision-making and system efficiency.

Paula Chidwick (left), Angel Petropanagos (centre), and Jill Oliver (right) working in the Ethics Quality Improvement Lab (2017).

For example, through training and mentorship from Health Quality Ontario’s IDEAS Advance Learning Program, we have learned to test change ideas, track progress, and evaluate changes. The PoET project that aims to reduce error-based transfers from long-term care to the hospital uses run charts to determine the normal range of variation for transfers and then to identify and interpret any changes. During PoET’s operation there was a 68% reduction in the number of long-term care residents who had multiple transfers from long-term care to hospital at end of life. In all our projects measurement plans including balancing, process, and outcome measures are utilized towards ensuring the changes we make through our activities are improvements.

In addition, our approach requires people to start to think differently about the challenges before them and to do things differently going forward. This is challenging work. Helpful in increasing understanding on how groups of people change is the Diffusion of Innovation theory. It uses a curve to describe the process by which people change or adopt innovations. The early adopters first embrace new ideas, then the early majority come on board, then the later adopters and so on. Each group along the change curve requires a different strategy to encourage a new way of thinking and doing. When we understand where individuals are along the change curve we can better support them.

Also helpful is the analogy called the Rider, Elephant and Path found in Switch by Heath & Heath. In this analogy, which builds on the work of Jonathan Haidt, the Rider represents the rationale for change, the Elephant represents the emotions people feel about change, and the Path represents the environment where change is happening. It’s important to direct the Rider with information, motivate the Elephant to want to change, and shape the Path by removing any barriers to change. Change is hard and this analogy helps us better identify challenges and opportunities for supporting healthcare professionals to change.

Finally, successful EQI Projects rely on adaptive leadership concepts. The work of Heiftez and Linsky provides clarity on technical and adaptive challenges in change. In general, technical solutions are insufficient for solving adaptive challenges. For example, the CHELO Project includes a Checklist, which is a technical solution for documenting information about a patient’s substitute decision maker, advance care plans, and their wishes, values, and beliefs. Yet, the Checklist itself cannot do all the work of change. It is people who need to think differently about the importance of knowing information that matters to patients. The adaptive work in the ChELO Project is addressing healthcare professionals’ uncertainty related to these types of conversations.   

In summary, our response to the changing health system is supported by quality improvement methodologies and change management concepts that provide a robust foundation on which our EQI Projects can spread and scale. The new ideas supported by our EQI Projects are leading change for better care. If you want to learn more about what we do, check us out at the Ethics Quality Improvement Lab.

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Angel Petropanagos is the Quality Improvement Ethicist at William Osler Health System. @APetropanagos

Paula Chidwick is the Director of Research and Corporate Ethics at William Osler Health System. @PMCEthics

Jill Oliver is the Community Ethicist at William Osler Health System. @joethics

@EthicsQI