Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Quality Measurement and Improvement
Lecture:Role of IT and informatics
Results of current approaches to quality assessment
Slide content:Ethical Issues Patient consent Treat as part of care or like research with human subjects protection (Lynn et al., 2007; Snyder & Neubauer , 2007; Miller & Emanuel, 2008)? Not paying for preventable complications Some obvious (e.g., objects left in patients), others less so (e.g., ventilator-associated pneumonia) ( Pronovost , Goeschel , & Wachter , 2008) Tensions between Customers and purchasers in US system (Milstein & Lee, 2007) Needing to improve care and knowing how to do it ( Auerbach , Landefeld , & Shojania , 2007) Physician internal motivationsnot found to be adversely impacted in one UK study (McDonald et al., 2007) 19
Slide notes:There are also some ethical issues for brief analysisfurther exploration of the papers listed on this slide is highly recommended for those who seek a deeper understanding of ethical issues. One issue concerns patient consent. When someone takes part in a research project, theres a process of protection for human participants. This issue came to the fore when a research project looking at the implementation of quality measures had not been properly vetted by the institutional review board or the human subjects committee to determine whether the research protocols were ethical. So a decision needs to be made on whether to treat quality interventions as part of patient care or as research. Lynn, Snyder, and Miller explore this issue and tend to advocate that it be viewed as part of care. There is also the issue of who pays for preventable complicationsits advocated that the patient not be responsible. Of course, the challenge is the identification of truly preventable complications. It is obvious that an object left in a patient is a preventable complication, and most would agree that the organization should be penalized in some way. Other complications, however, are less obvious. When a patient gets pneumonia on a ventilator, is it because the patient was insufficiently suctioned? or improperly moved? or not put into isolation? Whether such a case of pneumonia is truly a preventable complication is unclear, and the question of whether it should be paid for is a little murky. The Affordable Care Act raised a similar potential issue with the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to participating hospitals that have excess readmissions of patients within 30 days of their hospital discharge. There are also tensions regarding quality issues. For example, customers and purchasers may have different priorities when it comes to quality measurement. Customers may want to see everything and have everything focused on their improved care. Purchasers may be more focused on the economic aspects. Tension also exists between the desire to improve care and not always having knowledge of the best ways to do so. There may also be tensions between a physicians internal motivations for his or her patients and P4P initiatives. One study fortunately found that the internal motivations of physicians were not adversely impacted in a P4P situation. 19