Charting the Future: Credentialing, Privileging, Quality, and Evaluation in Clinical Ethics Consultation
Dubler, Nancy Neveloff, Webber, Mayris P., Swiderski, Deborah M., The Hastings Center Report
Clinical ethics consultation has become an important resource, but unlike other health care disciplines, it has no accreditation or accepted curriculum for training programs, no standards for practice, and no way to measure effectiveness. The Clinical Ethics Credentialing Project was launched to pilot-test approaches to train, credential, privilege, and evaluate consultants.
When difficult decisions must be made about health care, clinical ethics consultation provides an additional resource and a conduit for complex communication among patients, their families (including relatives, significant others, close friends, and appointed surrogates), and the care team. CE consultants address some of the most divisive and contentious issues in American society. While other disciplines, such as chaplaincy and palliative medicine, have developed training standards (1) and become viable, funded disciplines within the medical center, clinical ethics consultation (CEC) has yet to mature. Although there are stipulated competencies for consultants, (2) there is no agreement on (1) standards for practice (outside of the Veterans Administration system), (3) (2) qualifications for practitioners, (4) or (3) valid and reliable measures to rate the quality and effectiveness of the CEC process. (5) There is neither accreditation for training programs nor an accepted curriculum for what such programs should teach. Finally, there has been no agreement that these clinicians must be credentialed and privileged in order to practice, in contrast to what is required for all other health care professionals.
The patient safety movement and quality improvement practices in health care have changed how insurers, the federal government, and patients rate and measure excellence in health care delivery, and increasingly they will determine how care is reimbursed. CEC has remained insulated from these evaluations, however--a fact that must change if its full potential is to be realized. It was precisely to bring about this change that the Clinical Ethics Credentialing Project (CECP) was launched. The project aimed to pilot-test possible approaches to training, credentialing, and privileging clinical ethics consultants and evaluating their work. It enrolled twenty-eight professionals, previously trained in the Montefiore-Einstein Certificate Program in Bioethics and Medical Humanities, who worked at the New York City Health and Hospitals Corporation, and forty-two previously trained professionals from a variety of hospitals surrounding New York City. Some applicants to the program who had not graduated from the Montefiore-Einstein certificate program were tested to gauge their fluency with health care ethics topics. The faculty--who were recruited from Bellevue Hospital and from Montefiore Medical Center--designed the program, taught the participants, and reviewed written assignments. For privacy reasons, HHC and non-HHC hospitals were grouped separately for teaching and discussion, although all case materials were redacted.
In November 2008, a working group of nationally recognized experts in bioethics and CEC convened to critique the project and advise the CECP on its products and processes. The goal of the meeting was to examine the project's experience and see if consensus was possible among these experts on standards for the organization and practice of CEC. Given the group's depth and diversity, its findings should reflect the current state of CEC in the United States.
The working group identified the following salient characteristics of a CEC service, comparable to other clinical services:
* The CEC service should be staffed by professionals whose education, experience, and present ability receive a high level of scrutiny.
* The CEC service should have a clear and transparent process.
* CE consultants should have the respect and support of clinical and corporate authorities in their institutions. …