The Cambridge textbook of bioethics

healthcare organizations – the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – adopted a new set of Principles of Organization and Management Effectiveness in 1989 that strongly emphasized a systems approach to continuous quality improvement in patient care (JCAHO, 1991).

Unfortunately, clinical ethics has not caught on to this trend toward systems thinking in healthcare. To the contrary, clinical ethics has continued to focus more on the particulars than the general: more on, for example, reacting to acute situations on a case-by-case basis than on identifying and addressing the underlying systems factors that give rise to many of the ethical concerns in healthcare (Silva, 1998).

Why is it important to apply systems thinking to clinical ethics?

In 2001, three long-standing leaders in the field of clinical ethics wrote a paper that highlighted the history of clinical ethics, talked about key developments in the previous decade and outlined remaining challenges for the field in this decade (Singer et al., 2001). The two top significant challenges they highlighted for clinical ethics practice (consultation and committees) was the need to integrate clinical ethics work into the culture of healthcare organizations and to improve organizational accountability for clinical ethics. What these authors were pointing to is a need to understand and impact the functioning of the larger context (the system) in which the ethical issues in healthcare exist.

A systems approach to clinical ethics offers a potential for significant impact across a broad scope of healthcare. Practically speaking, a systems approach focuses on the dynamic ‘‘assemblages of interactions within an organisation or between organisations’’ (Emanuel, 2000). As a result, this perspective can impact the broader healthcare culture and address the ‘‘silo’’ problem in clinical ethics consultation (where the consultation service

is perceived to operate in relative isolation from the rest of the organization) (Blake, 2000). A systems approach can improve ethics accountability by demonstrating a systemic commitment to ethics, by integrating ethics from ‘‘boardroom to bedside’’ (MacRae et al., 2002), and by bridging the artificial gap between organizational and clinical domains (Foglia and Pearlman, 2004).

A systems approach can help clinicians, managers, and ethics facilitators to understand and address the components of the systems that drive ethical care and behavior. These components may relate to local dynamics and practice, or they may be broader in scope to include such things as financial models, information technology systems, philosophy of care issues, rewards and incentives, historical factors, or professional boundary issues. Systems thinking may also help to decrease moral distress and disempowerment among healthcare staff – a factor that has been shown to be a major cause of staff burn-out and turnover. Moral distress has been defined as ‘‘what happens when a staff person knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’’ (Jameton, 1984) and is something that lends itself to a deeper inquiry using systems thinking. Systems thinking applied to the problem of staff moral distress inquires into the systemic challenges that create painful ethical challenges for healthcare professionals, moving the solution beyond the staffs’ personal suffering to the possibility of changing institutional conditions that created this suffering in the first place. A similar approach can be used to move to a more patient-centered healthcare quality approach that addresses key patient and family concerns (Cleary and Edgman-Levitan, 1997).

A systems approach also helps to ensure that clinical ethics practice is collaborative with others in the healthcare organization or system. In the traditional models, clinical ethics programs and clinical ethics committees are poorly integrated across the organization and with other groups in the systems that have similar goals.

Finally, systems-based clinical ethics supports evidence-based practice and accountability to the end-users in healthcare. In this way the end-user provides the marker to the type of system that is in existence around a given situation and, therefore, lends insight into future opportunities for improvement. Such an approach requires serious study of the effects of various clinical ethics interventions on actual practice in order to drive innovation and change. This includes incorporating clinical ethics indicators into other system measurements such as patient satisfaction outcomes and accreditation scoring. The shift is one where a clinical ethics committee or consultant moves from asking questions such as, ‘‘Was this one consult or educational session successful?’’ to questions such as ‘‘How has clinical ethics impacted the overall healthcare culture in how it sets financial priorities, frames problems, addresses staff morale, etc?’’ – or even to such fundamental questions as, ‘‘Is this the system of healthcare we ought to have in order to achieve the goals we strive to achieve?’’

There are no regulatory requirements for ethicists in Canada, the USA or the UK, and no formalized competency requirements or understanding of ‘‘effective’’ clinical ethics practice. This lack of standards in clinical ethics is strangely accompanied by drive to require clinical ethics services by oversight bodies (Canadian Counsel on Health Services Accreditation, 2004; Royal College of Physicians, 2005; JCAHO, 2007). It is only a matter of time before ethicists are going to need to define what counts as effective practice. One danger in this shift towards effective practice is that ethicists will respond to this challenge by being too inwardly focused and will spend time exclusively on their own professional issues such as their working conditions, core competencies, and codes of conduct for ethicists without, at the same time, looking outwardly for impact on the people that ethics is meant to serve. A field that is too inward looking may soon make itself irrelevant in the broader healthcare context and die under its own weight. It seems that a reasonable approach for those

in ethics may, therefore, be to look beyond the characteristics of individual consultants and consultations to an examination of how clinical ethics interventions are actually affecting patients, healthcare professionals, and organizations and healthcare more broadly (Fox and Tulsky, 1996; Leeman et al., 1997). In this way systems-based clinical ethics programs can offer leadership in the field as a standard bearer to which regulating bodies may turn.

How should I apply systems thinking to clinical ethics in practice?

Changing organizational behavior and/or culture is no small task. As leaders of three large clinical ethics networks in three different countries, we have each been working for a number of years to find innovative ways to meet this challenge. In the USA, EF leads the National Center for Ethics in Health Care of the Veterans Health Administration, which is the largest healthcare system in the USA, with roughly 8 million enrolled patients, 200 thousand employees, and 1300 sites of care delivery. In the UK, AS leads the support program for the national network of clinical ethics committees. This programme includes a website (http://www. ethics-network.org.uk) and educational resources for all clinical ethics committees in the UK, of which there are approximately 85. In Canada, SM is the Deputy Director of the Joint Centre for Bioethics, a partnership with the University of Toronto and 15 diverse healthcare organizations in the greater Toronto area and with the largest group of in-hospital full-time clinical bioethicists in Canada and perhaps in the world.

Despite the fact that the authors work in three different countries, with three different cultures, healthcare-funding structures, and settings, we have all evolved independently towards systems thinking in our clinical ethics practice. Below we have identified our top 10 leading practices that we agree are essential when applying systems thinking to clinical ethics.

316S. K. MacRae, E. Fox, and A. Slowther

The top 10 leading practices in applying systems thinking to clinical ethics

Have a clear organizational mandate

A clear organizational mandate means that clinical ethics programs must have a well-defined organizational role, clear responsibilities and expectations for that role, and the status, authority, and resources needed to carry out that role.

EXAMPLE. The National Center for Ethics in Health Care (http://www.va.gov/ethics) is one of the major national program offices of the Veterans Health Administration. It is responsible for promoting ethical healthcare practices throughout the Veterans Health Care System and its roles and responsibilities are delineated in formal documents that are updated regularly. The Center’s Director is a senior executive who reports to the organization’s top leadership. The Center’s budget supports 20 fulland part-time staff members.

Be and stay engaged with the ‘‘real world’’

By engaging with the ‘‘real world,’’ we mean that the clinical ethics program must be well attuned to the everyday reality of the healthcare organization and the ‘‘real world’’ it seeks to affect. From our experience, historically two streams of activity have struggled to claim the ‘‘ownership’’ of the field of clinical ethics: the highly academic field of applied ethics on the one hand and the grassroots movement of clinicians, clinical programs, and hospital ethics committees on the other. This has often resulted in a split in the field of clinical ethics between scholars studying bioethics in universities, who often have extensive theoretical training but relatively little experience with day-to-day healthcare conflicts and operations, and clinicians and members of clinical ethics teams in hospitals, who may have little formal ethics training but understand very well the practical realities of the modern healthcare organization and the ethical dilemmas therein. Systems thinking allows one to move

beyond this ownership question to a question of impact and seeks to integrate theory and practice for the betterment of healthcare quality.

EXAMPLE. The University of Toronto Joint Centre for Bioethics (http://www.utoronto.ca/ jcb) seeks to bridge this theory-to-practice gap by involving scholars and practitioners alike in a common pursuit of ‘‘real world’’ bioethics solutions in an engaged way. These solutions range from ethics delivery models to evaluation studies of the field, as well as scholarship and models for practical problems faced by healthcare organizations and citizens. This approach involves engaging with the end-users of ethics knowledge in order to constantly redefine the models created in academia while at the same time presenting scholars with opportunities to apply their knowledge to actual dilemmas of the present reality of healthcare and its key stakeholders.

Take advantage of economies of scale

Application of a system-based clinical ethics program can benefit from creation of networks in a way that provides more impact and higher benefit and service to individuals belonging to the network than what they would be able to realize if a similar effort were made at the individual level.

EXAMPLE. The UK Clinical Ethics Network includes all clinical ethics committees in the UK linked to a small support team at the Ethox Centre (http://www.ethox.org.uk). This model enables widespread dissemination of educational material and information to the individual committees, which, in turn, supports them in their efforts to improve ethical practices within their organization and avoids duplication of effort. The network provides a facility for sharing experience, best practice, and new ideas between committees, increasing the rate at which clinical ethics can develop in the individual organizations. For example, a committee dealing with a difficult case consultation around confidentiality in clinical genetics

can use the network email system to access expertise in other committees, who may be able to share examples of policies they have developed on this issue. The resulting discussion and exchange of information is open to all committees, so good practice is disseminated throughout several institutions.

Be practical and useful

A clinical ethics program should be practical and useful: that is, it should be focused on serving the practical needs of the organization of which it is part and helping to advance the organization’s mission and goals. Some clinical ethics centers and programs have a strongly academic or theoretical bent, serving primarily as ‘‘think tanks.’’ Some see it as their mission to enhance dialogue [http://wings.buffalo.edu/faculty/research/bioethics/ news1], encourage debate [http://www.fom.sk.med. ic.ac.uk/medicine/about/divisions/ephpc/pcsm/ research/meu/], or enrich the moral imagination [http://www.ethics.emory.edu/]. In contrast, centers like ours are service oriented and focus on results. Specifically, we aim to improve actual on-the- ground ethical behavior throughout the healthcare organizations we serve.

EXAMPLE. The mission of the National Center for Ethics in Health Care of the Veterans Health Administration is explicitly practical and behavior based. One of the Center’s major national initiatives, called IntegratedEthics, is an organ- ization-change initiative designed to help individual healthcare facilities improve ‘‘ethics quality’’ at three levels: decisions and actions, systems and processes, and environment and culture. ‘‘Ethics quality’’ is seen as essential to the core mission of the Veterans Health Administration: delivering high-quality healthcare.

Be proactive, not reactive

Systems thinking allows clinical ethics to be proactive and not just reactive. In the case of current

ethics consultants, the practicing lone bioethicist often struggles with isolation and overwork, and lacks appropriate integration, sustainability, and accountability to move beyond a few priorities and reactive efforts (MacRae et al., 2002). Clinical ethics needs to function strategically if it is to do any more than react to crises. Clinical ethics that is geared at systems change is not as focused on the crisis situations as it is on the overall context of these situations, which may allow for more thoughtful, systematic, well-thought-out strategic directions for ethics interventions. As clinical ethics becomes more systems focused, interventions (e.g., consultation or educational sessions) are seen as opportunities to understand the ‘‘root cause’’ of a problem or behavior and to suggest changes or alternative systems models that will reduce rather than create ethical difficulties for clinicians and patients. The goal is wider than resolving the immediate ethical conflict involving an individual patient and his or her clinicians. In some cases, it can be to eliminate the underlying cause of the ethical conflict completely from the system. This ‘‘upstream approach,’’ which looks at what causes the problems or what leads to certain behaviors, focuses not on the failures of individuals but instead on the opportunities in the system for improved outcomes. Ethicists may also choose to impact public policy, for example by choosing to collaborate with clinicians or scholars to conduct research to influence a thoughtful response to a larger trend they are noticing in the field. Or they may plan overall goals through a formal ethics strategic-planning process (Gibson et al., 2007) to help to highlight the institution’s priorities with respect to ethics.

EXAMPLE. At the University of Toronto Joint Centre for Bioethics, an affiliated hospital was asked to create an ethics framework for allocation of scarce resources in the event of pandemic influenza. This framework was developed locally but was then adopted by the provincial health ministry as the ethical framework for the provincial plan. A white paper Stand On Guard for Thee (http://www.utoronto.ca/jcb/home/ documents/pandemic.pdf) was also generated,

318 S. K. MacRae, E. Fox, and A. Slowther

which was subsequently adapted by healthcare organizations and health systems internationally, including the World Health Organization.

Build relationships

If the goal of clinical ethics is to effect change in the healthcare system then it requires that the ethics program/committee liaise and build relationships with others in the organization or region. These linkages may be with other departments, such as quality, patient relations, or risk management, or with key senior leaders and university scholars. One of the failures of traditional ethics committees has been that it often lacks the necessary relationships within the system to move the understanding of unique ethics problems to other parts of the system and thus effect more global change to systemic problems. A systems-based clinical ethics program builds networks of individuals from a variety of backgrounds. Programs that value the involvement of these different disciplines and that builds transdisciplinary communities enables the necessary critical approach that many ethics problems require. This diversity allows for a rich complexity of views and perspectives in the analyses, which can provide solutions that are well rounded, supportive, and inclusive.

EXAMPLE. The UK Clinical Ethics Network acts as a link between the clinical ethics community ‘‘on the ground’’ and national organizations such as the General Medical Council and other professional bodies, facilitating ethical dialogue within the regulatory systems that guide professional practice. This provides local input into development of national policies governing professional behavior and improves the implementation of professional guidance at a local level.

EXAMPLE. At the University of Toronto Joint Centre for Bioethics, the Clinical Ethics Group (made up of the 22 clinical bioethicists and the seven clinical ethics fellows) meets for three hours each week for ethics rounds,

case conference, and continuing education seminars. The group is also linked via an electronic listserv. Through this interdisciplinary group space, a sense of community is strengthened and harnessed to share material and resources, review cases, learn new material, conduct research and joint projects, and support each other emotionally and professionally. This community of support and practice has shown itself to be a key factor in the capacity of the bioethicists to do their work. Many bioethicists now consider community as a key factor in their effectiveness.

Maintain a constant improvement orientation

An improvement orientation focuses on achieving continuous improvement throughout the system: setting up an iterative process between individual committees, local programs and larger institutional bodies to develop and evaluate systems change. Providing a research or evidence base to clinical ethics system’s approaches is a critical factor for achieving effectiveness in this field. The evidence may come from the use of case studies and the distillation of key themes and good practices.

EXAMPLE. The National Center for Ethics in Health Care is spearheading a system-wide initiative to improve the quality of ethics consultation in Veterans Health Administration medical centers nationwide. A central part of that effort is the development, field testing, and deployment of ECWeb: a secure, webbased software program designed to standardize ethics consultation processes and to provide an electronic method of documenting, storing, and retrieving ethics consultation data. In addition, ECWeb can generate reports of service utilization, consultation processes, and participant satisfaction. Other features of ECWeb include secure access to authorized users through the Veterans Administration’s own internet system, stratified access to information on a need-to-know basis, ability to

designate certain consultation records as quality-improvement reviews with special legal confidentiality protections, automated (email) reminders of planned consultation activities, automated (email) notification of consultation referrals, ability to attach electronic documents to records (e.g., Word documents, PDF files), ability to search records by key word, and categorization of consultations into standardized content domains and topics for quality improvement and reporting purposes.

Understand key stakeholders

Understanding the individuals or groups that can affect or be affected by an ethics program is also essential. To be effective, an ethics program must be able to reach its stakeholders and earn their trust. This requires insight into stakeholder characteristics, including their preexisting knowledge, how they like to receive information, plus their needs, interests, and values. Effective ethics programs appreciate the importance of understanding their stakeholders and actively seek out information to inform their approach.

EXAMPLE. The recent Project Examining Effectiveness (PEECE) research study conducted at the University of Toronto’s Joint Centre for Bioethics (Godkin et al., 2005) asked key stakeholders, including patients/families, healthcare staff and physicians, bioethicists, ethics committee members, and senior healthcare administrators and funders, to define clinical ethics and what they consider to be effective clinical ethics practice. This grassroots case-study approach to examining clinical ethics effectiveness allowed for a more nuanced snapshot description of what the endusers of healthcare think, rather than prescribing a model created by bioethicists. A similar model is currently being applied to case studies in organizational ethics as a method to elucidate current practices and lessons in this area.

Ensure accountability for the ethics program

Accountability requires that ethics committees, consultants, and programs work to an appropriate standard, have clear lines of reporting, and are situated in such a way to impact change at the level required at the institution.

EXAMPLE. Clinical ethics committees in the UK are situated within the clinical governance structure of each institution. This ensures that the work of the committee feeds into clinical management by raising awareness at an executive level of the issues facing clinicians on the ground. It also provides an opportunity for the committee to play an active role in policy and guideline development within the institution. The UK Clinical Ethics Network is currently developing guidance for all committees on core competencies, and on procedures for assessing the acquisition and maintenance of competencies by committees. This includes an ability to identify and engage with ethical issues at a systems level as well as responding to individual conflicts within the system.

Target root cause organizational factors that influence behavior

Many ethics programs make the mistake of focusing exclusively on specific decisions and actions on a case-by-case basis. But to have a real and lasting impact on ethical behavior, ethics programs must target not just individual behaviors but also the underlying root cause organizational factors that influence them. In particular, individual behaviors are powerfully influenced by an organization’s systems, processes, environment, and culture (http://www.va.gov/integratedethics/primer.cfm).

If an ethics program focuses only on specific decisions and actions, without addressing broader organizational influences that may facilitate or impede ethical practices, employees are more likely to experience moral distress or a feeling that they know the right thing to do but are unable to do it (http://www.cna-nurses.ca/cna/documents/

320S. K. MacRae, E. Fox, and A. Slowther

pdf/publications/Ethics_Pract_Ethical_Distress_ Oct_2003_e.pdf#search=%22moral%20distress%22). In contrast, when ethics is integrated throughout an organization’s systems, processes, environment, and culture, employees recognize ethical concerns and discuss them openly. They feel empowered to behave ethically and know they will be supported when they ‘‘do the right thing.’’

EXAMPLE. The IntegratedEthics initiative of the National Center for Ethics in Health Care is a multilevel organizational change project that is being rolled out to all Veteran Health Administration facilities nationwide. The initiative seeks to improve ‘‘ethics quality’’ by explicitly targeting not only individual decisions and actions but also the underlying factors that influence behavior. It includes specific mechanisms for dealing with ethics quality gaps on a systems level, as well as specific interventions for fostering a positive ethics environment. The initiative’s evaluation tools assess not only specific ethical practices but also ethics-related structures, processes, environment, and culture (http://www.va.gov/ integratedethics/index.cfm).

The cases

Both of the cases at the beginning of this chapter represent scenarios that could benefit from systems thinking. In the first case, the situation is based in a health region that spans many healthcare delivery sites, while the second scenario is based in an organization. In both cases, a systems approach to clinical ethics requires an explicit recognition by clinical ethicists and other ethics facilitators of the different interrelational systems of values within and outside the organization as well as a focus on culture-wide ethical integrity.

More specifically, a systems approach to clinical ethics in these cases requires using the original functions associated with clinical ethics – consultation, education, policy development, and scholarly work – for the purpose of improving the overall

culture and system of care delivery, including, but moving beyond, care of the individual patient. It means seeking an impact at all levels of the organization from ‘‘boardroom to bedside,’’ making ethics as available and visible at senior executive meetings for example, as it is in clinical rounds. It means working with senior leaders to effect change throughout the organization, sitting at the senior tables and clinical tables and offering useful and effective tools and resources to help them to manage the real problems they face. It requires that the ethicist understands the context of healthcare and its business model and structure in order to identify how change can occur within that particular setting, while still appreciating the considerable variation in cultures that occurs from one healthcare organization to another. It may also mean building liaisons with other departments and with professionals focused on organizational change, such as quality departments, patient relations, and risk management, while maintaining the unique viewpoint that ethics offers to the discussions that usually surface in these arenas. It means acknowledging the many different ethical codes (professional, financial, personal) and clashes that exist in the complex systems of healthcare (Thurber, 1999). It also means integrating ethics into the key ‘‘thrust’’ areas in the network, organization or region (such as patient safety, pandemic influenza planning) as an important contribution from ethics that may affect the overall system of care.

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Canadian Council for Health Services Accreditation (2004). The Canadian Health Accreditation Report 2004. Ottawa: Canadian Council for Health Services Accreditation. (http://www.cchsa.ca/pdf/2004report. PDF), accessed 5 June 2006.

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A large tertiary healthcare organization has a full-time clinical ethicist who is responsible for ethics consultation, education, policy development, and research. A recent accreditation survey identified a number of gaps in clinical ethics services across the organization. The clinical ethicist is already over-extended and is at risk of burning out. The Vice-President responsible for overseeing the ethics portfolio wonders what can be done to enhance support for the clinical ethicist, strengthen ethics capacity across the organization, and improve the overall effectiveness of clinical ethics services.

What is clinical ethics effectiveness?

The ultimate goal of any clinical ethics delivery model is improved patient care. As more healthcare resources are invested in clinical ethics services, questions are increasingly raised about whether these services are effective in improving the quality of patient care and whether they justify investments of limited healthcare resources. In this chapter, we identify some key challenges to existing clinical ethics delivery models and suggest four innovative strategies to improve effectiveness in clinical ethics services in healthcare organizations.

Since 1995, when James Tulsky and Ellen Fox convened the Conference on Evaluation of Case Consultation in Clinical Ethics (AHCPR, 1995), there has been a marked increase in scholarly attention to the study and evaluation of clinical ethics, particularly related to the ethics consultation component of clinical ethics (e.g., McClung et al., 1996; Orr et al., 1996; Schneiderman et al., 2000). This has

been described as a new phase in the clinical ethics movement (Aulisio, 1999). As the field of clinical ethics continues to develop, it will not be sufficient for clinical ethicists ‘‘merely to mean well’’; they must also be able to demonstrate effectiveness (Aulisio, 1999). While the goals of clinical ethics are generally clear – namely, the identification, analysis, and resolution of ethical concerns arising in the delivery of patient care (Siegler and Singer, 1988) – it remains unclear how clinical ethics effectiveness should be defined and evaluated.

Defining and evaluating clinical ethics effectiveness is complex for several reasons: (i) the different perspectives of multiple stakeholders on effectiveness (e.g., healthcare managers, patients, clinicians, society), (ii) the different levels at which evaluation can take place (i.e., individual ethicist, clinical ethics service, organization), and (iii) the diverse activities within the clinical ethics portfolio that must be evaluated (i.e., consultation, education policy development and research) (Griener and Storch, 1992; Aulisio et al., 2000). To date, most evaluative efforts have focused on identifying core competencies for clinical ethics practice (ASBH, 1998) and benchmarks of clinical ethics effectiveness from the perspective of those who deliver the services (Godkin et al., 2005). The perspectives of other stakeholders, such as patients, family members, and healthcare managers, have not been adequately explored (Cleary and Edgman-Levitan, 1997). For healthcare organizations, the most relevant concern is whether clinical ethics services are effective in improving local delivery of patient care.

Consequently, the unique patient populations served by an organization, existing clinical ethics capacity within the organization, and the mission and values of the organization would be key considerations in evaluating the effectiveness of clinical ethics service in improving patient care. So while it is important that there be a continued emphasis on identifying evidence-based practices in clinical ethics and developing general benchmarks of clinical ethics effectiveness to use across clinical ethics programs, some component of evaluating clinical ethics effectiveness will necessarily be context dependent.

research ethics), policy development, education, and research (Storch and Griener, 1992; McNeill, 2001; Slowther et al., 2001). The lone ethics consultant model faces three challenges: integration, sustainability, and accountability (Silva, 1998; Berchelmann and Blechner, 2002; MacRae et al., 2005). When accountability for clinical ethics is delegated to the clinical ethicist alone, it is difficult to achieve integration of ethics across the organization and to meet demand for clinical ethics support in a sustainable way. Accessibility of clinical ethics services among patients and family members is often particularly limited within this model.

Why is clinical ethics effectiveness important?

Ethics is increasingly recognized as an important component of high-quality clinical care (Woolf, 1994; Cleary and Edgman-Levitan, 1997; Wynia, 1999, 2006; CCHSA, 2004; JCAHO, 2007). Indeed some commentators, such as Wynia (2006), have suggested that ethics ‘‘just might be the realm of quality that many patients care about most of all.’’ Demonstrating clinical ethics effectiveness is important in healthcare institutions for the purposes of assessing quality and identifying areas for improvement, increasing efficiency and impact, justifying allocation of resources, influencing policy, and disseminating knowledge (Silva, 1998; Wynia, 2006). Additionally, in Canada and the USA, accreditation standards now require healthcare organizations to have formal mechanisms in place to help staff to deal with ethical issues related to client care and business practices (CCHSA, 2004) and to demonstrate ‘‘ethical behavior in care, treatment, and services and business practices’’ (JCAHO, 2007).

The dominant model for clinical ethics service delivery in healthcare institutions has been the lone ethics consultant model – also referred to in the literature as the ‘‘lone ranger’’ (Fox et al., 1998) or ‘‘beeper ethicist’’ model (McGee, 1995) – operating with or without the support of an ethics committee. The role of the clinical ethicist (or ethics committee) generally includes ethics consultation (including

How should I approach clinical ethics effectiveness in practice?

In this section, we describe four innovative strategies to improve the effectiveness of clinical ethics services in healthcare organizations. These practical strategies were developed and piloted by the University of Toronto Joint Centre for Bioethics (JCB) in response to the challenges identified above: integration, sustainability, and accountability. The JCB is a partnership network among the University of Toronto and 15 health organizations (13 academic and/or community hospitals, one community care access center, and one science organization), each of which has at least one full-time clinical ethicist. The strategies include (i) the ‘‘hub and spokes’’ model for clinical ethics service delivery, (ii) leadership and management skills training for clinical ethicists, (iii) ethics strategic planning, and (iv) evaluation of clinical ethics services.

Strategy 1: the ‘‘hub and spokes’’ model for clinical ethics service delivery

The hub and spokes model is an innovative model of clinical ethics delivery. In contrast to the traditional lone ethics consultant model, the hub and spokes model envisages an integrated institutionwide ethics network comprising the clinical ethicist (‘‘hub’’), who provides core ethics leadership, and