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Evaluating ethics committees.

Are ethics committees "doing good?" If so, how do they accomplish this and who benefits from their efforts? What effects have they on the individuals and institutions they serve? Since ethics committees have been part of the health care system for more than a decade, the time has come to consider ways of evaluating their effectiveness. Committees in our network have been developing various approaches to self-assessment

Most ethics committees perform several functions-typically, education, policy development and case consultation. Their performance in each of these areas must be evaluated to determine where committees are most and least effective. This information can then be used to plan future activities so as to achieve greater overall impact.

Selective evaluation according to function, however, may produce a skewed picture; assessment of overall performance is also necessary. We believe that retrospective review, a fourth function of these committees, can provide ongoing evaluation of committee operations as a whole. Retrospective review involves looking back over completed cases in which ethically difficult patient care situations are identified to determine whether more staff or patient education is needed and whether institutional policies and case consultation procedures are adequate and used.

It seems logical to assume that the mission statement of an ethics committee will provide some basis for measuring committee performance in retrospect-at the very least, for determining whether a committee is meeting the expectations of its founders. If the mission statement does not provide a basis for developing evaluation criteria, it may be too vague, unrealistic, or inappropriate.

We reviewed the mission statements of nine ethics committees in our area. All indicated that they were to be a forum," which several further defined as a place where staff could come to discuss ethical issues, dilemmas, and concerns. One committee's statement contained two specific goals for its members: "To come to an awareness of the divergent value systems which influence choices people make" and "To learn to think effectively and dialogue meaningfully with each other as we come to decisions." These goals are detailed enough to allow members and researchers to develop a survey tool by which to measure desired process and outcome achievements. The next step would be to create some means of showing how increased awareness of different values, effective thinking, and significant interchanges benefit the institution and those whom it serves-a challenging task. One approach to determining the effectiveness of a committee as a forum is to measure "meaningful dialogue," or the absence of it. We have observed that in those committees where discussion is dominated by a few individuals, there does not seem to be a feeling of openness. Perhaps committee chairpersons could note the degree of participation by individual members in deliberations and prepare a dialogue ratio" or some such measure of discussion, as one index of forum achievement. We also solicited evaluation measures indirectly from members of ethics committees in our network by asking them how they would respond to the following question: "What has your committee accomplished?" We have received three consistent types of responses to date: 1) The committee's educational efforts have created greater sensitivity to ethical issues throughout the institution, as evidenced by increasing numbers of requests for additional educational programs and case consultations. 2) The committee has been responsible for initiating, reviewing, or revising institutional policies for decisionmaking related to patient care, especially resuscitation policies.

3) The committee has evolved into a forum where persons of various professional disciplines share mutual respect and trust so that various ethical issues and dilemmas can be discussed openly.

These are primarily process results reflecting an underlying assumption that effective education, sound policies, and defined process bring good outcomes.

Committee members sometlmes receive information or observe practices that can guide the committee in developing formal evaluation criteria and procedures. For instance, the chairperson of one ethics committee noted that requests for case consultations increased after each educational program that the committee organized for staff. The number and type of such requests are now being documented in an attempt to develop criteria for measuring the effectiveness of the programs and to determine future educational needs. Evaluation is not an end in itself, but also a means of developing committee effectiveness.

A number of committees audit charts to determine the kinds of policies that would be useful to caregivers and patients. One nursing home ethics committee has reviewed patient records in which a CPR or DNR order was written or in which there is a notation that CPR would be performed (because no decision was made against it) to assess whether the policy of discussing DNR orders with patients and families is known and followed in the institution. activity of committees is also underway. The consultation subcommittee of one hospital ethics committee sends an evaluation form to the initiator of a case review one week after the review has been completed to gain his or her perceptions of the process. The response is used to modify or strengthen the group's consultation procedures.

In each of these cases, feedback has been a key element in initiating an evaluation process. A method must be established to ensure that subsequent responses are systematically collected and processed so that evaluation efforts can be developed and redirected in light of them.

Numerous other questions about evaluation have come to the fore:

- Should committees evaluate themselves or is outside evaluation preferable?

- Can the Presidents Commission's reservations regarding ethics committees be converted into criteria and objective measures?

- Are ethics committees cost effective? Should they be?

- Are ethics committees facing greater pressure to develop evaluation measures than IRBs and other hospital committees? If so, why?

We know that others are pondering similar questions, and welcome opportunities to exchange ideas and experiences concerning evaluation with ethics committees around the country.
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Author:Van Allen, Evelyn; Moldow, D. Gay; Cranford, Ronald
Publication:The Hastings Center Report
Date:Sep 1, 1989
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