Injecting Ethics into the Public Health Quality Improvement / Accreditation Movement Kathy Vincent, LCSW Alabama Department of Public Health Ruth Gaare.

Injecting Ethics into the Public Health Quality Improvement / Accreditation Movement

Kathy Vincent, LCSWAlabama Department of Public Health

Ruth Gaare Bernheim, JD, MPHUniversity of Virginia

Alan Melnick, MD, MPH, CPH

Health Officer, Clark, Cowlitz, Skamania, and

Wahkiakum Counties

Overview

• Case Example• Public Health Code of Ethics• Crosswalk of Public Health Accreditation and the

Public Health Code of Ethics• Discussion

Case Study: Water Supply

• Environmental factors• Testing results• Studies• Health Effects

Case Study: Water Supply (Discussion)

Discussion issues we will return to in a few minutes:

• What would you do?

• What ethical issues are being raised?

• How might the accreditation process strengthen your department’s ability to address or respond to this situation?

Case Study: Water Supply

Would you act any differently if:• Birth defects associated with mineral Y exposure are

small (inguinal hernia, incurving of fifth finger, single palmer crease )?

• Mineral Y is also an ingredient in a cola drink widely consumed over many years by people of all ages?

• Mineral Y has recently been used as a chemical agent to intentionally contaminate water in Pakistan?

Poll 1

Would you act any differently if a different water source at a high price could supply your city?

Yes

No

Poll 2

Would you act any differently if a different water source at no extra cost and without shortages could supply your city?

Yes

No

Linking Accreditation Process & Core Values

Quality Improvement

Techniques to improve performance and outcomes

“Multidisciplinary, systems- focused, data-driven method of understanding & improving

the efficiency, effectiveness, and reliability of public health

processes and practices.”

Rand Report ’06

Accreditation Opportunity for health

departments to learn and incorporate quality and

performance improvement techniques

Linking Accreditation and Core Values• Focus: Performance measures and outcomes

• Depends on the organization's goals, which grow out of an organization’s core values / principles and mission

• Internal versus external process

Linking Accreditation and Core ValuesLessons from corporate management• Have explicit core values• Define the enduring character of an organization (similar

to Declaration of Independence) • Start with descriptive statement of “We deliver X

services” and then ask 5 times “why is that important”• Create vision, goals, and measurements from core

values

Built to Last Collins and Porras

The Seven Factors of Excellence

Teamwork

)

Vision Mission

Core Values

Innovation

Quality(Accreditation)

Responseto External

Change

Customer& Client

Orientation

Leadership& EmployeeOrientation

From Duncan & Ginter

Public Health

Activities and Policies

Legal Issues

Public Health Context

Public Health EthicsIssues

Why Consider Ethics

“…laws are often broadly framed, leaving much room for

administrative discretion about when to use public health

authority and about which intervention is more ethically

appropriate when more than one alternative course of action

is legally permissible.”

Bernheim RG, Nieburg P, and Bonnie RJ. “Ethics and the Practice of Public Health,” in Goodman RA (ed.), LAW IN PUBLIC HEALTH PRACTICE, 2nd ed., Oxford, New York, Oxford University Press (2005).

Definitions and Concepts

Law in Public Health Ethics in Public Health

Provides authority, limitations on state power, incentives and disincentives for behavior

Often allows for much professional discretion

Provides ongoing analysis, deliberation about, and justification for public health action and policy

Often when law is indeterminate

Definitions and Concepts

Law • Formal institution

Statutes Regulations Court decisions

• Public proceedings with a “reasonable person” standard

Ethics • Less formal

Moral norms, values

Professional codes Previous cases

• Publicly justifiable positions, based on ethical reasoning

Administrative Discretion Under the Law

TB Outbreak in a Community

Ethics• Decide by case how to

use legal authority• Demonstrate when

imposing detention that protecting the public’s health overrides an individual’s moral claim

• Act with transparency and accountability: “We are imposing detention because…”

Law• Authority to detain

individuals who are non-compliant with the TB treatment regimen

What Is The Code?

• Has twelve key principles of the ethical practice of public health

• Can be cross-walked with public health practice to foster alignment with the Twelve Ethical Principles

Public Health Code of Ethics Background • Development by a workgroup

of the Public Health Leadership Society

• Process included a broad range of stakeholders from public health practice to academia

• Code is a living document

http://www.phls.org

Role of the Code in Accreditation

Rationale for including public health ethics in development of each accreditation standard•Accreditation efforts often cite ethical value of accountability

•Application of the Principles demonstrates that other values are relevant, such as role of accreditation in increasing transparency and fostering community trust

Role of the Code in Accreditation

Flexibility allows public health ethics to be incorporated into different accreditation approaches • Principles do not require particular mechanisms,

such as ethics committees, but allow for experimentation with various approaches to community involvement

Role of the Code in Accreditation

• Principles can be applied in different areas of public health practice

Examples: disease control and public health genomics

• Principles are compatible with movements to accredit particular programs

Example: accrediting public health research ethics review

Standards Development

• Based on the 10 Essential Services

• Uses operational definition of a functional local health department (LHD)

• Several states developing state-specific standards for LHDs

• National Public Health Performance Standards Program (NPHPSP) includes standards for local public health systems

• Consistency in standards developed by NACCHO, the states, and NPHPSP

Standard Domains

1. Monitor health status and understand health issues.

2. Protect people from health problems and health hazards.

3. Give people information they need to make healthy choices.

4. Engage the community to identify and solve health problems.

5. Develop public health policies and plans.

6. Enforce public health laws and regulations.

7. Help people receive health services.

8. Maintain a competent public health workforce.

9. Use continuous quality improvement tools to evaluate and improve the quality of programs and interventions.

10. Contribute to and apply the evidence base of public health.

11. Govern and manage health department resources (including financial and human resources, facilities, and information systems).

Public health (PH) should address fundamental causes of disease and requirements for health

PH should achieve community health in a way respecting individuals’ rights

PH policies, programs, and priorities should be developed / evaluated with community members’ input

PH should work to empower disenfranchised community members, aiming to ensure access to basic resources necessary for health

Principles of the Ethical Practice of Public Health*1

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The Public Health Code of Ethics

* Principles of the Ethical Practice of Public Health, The Public Health Leadership Society (2002), http://www.phls.org

The Public Health Code of Ethics

PH should seek information needed to implement effective policies / programs that protect and promote health

PH institutions should provide communities with information needed for policy / program decisions and should obtain community’s consent for implementation

PH institutions should act in timely manner within resources and mandate given by public

PH programs / policies should incorporate approaches that respect diverse values, beliefs, and cultures in community

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The Public Health Code of Ethics

PH programs / policies should be implemented in manner that most enhances physical and social environment

PH institutions should protect confidentiality of information that can bring harm to individual or community if made public

PH institutions should ensure their employees’ professional competence

PH institutions and their employees should engage in collaborations and affiliations that build public’s trust and institution’s effectiveness

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Domain 1 (Monitor health status and understand health issues)

Ethical Principles

Obtain and maintain data that provide information on the community’s health

Health services data, environmental data, data on disparities such as poverty, lack of affordable housing, limited or no access to transportation etc.

Analyze data to identify trends, health problems, environmental health hazards, and social and economic conditions that adversely affect the public’s health.

1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes

4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.

Develop relationships with local providers and others in the community who have information on reportable diseases and other conditions of public health interest and facilitate information exchange.

3. Public health policies, programs and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.

6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.

12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

Integrate data with health assessment and data collection efforts conducted by others in the public health system.

Conduct or contribute expertise to periodic community health assessments.

12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.