Special Report: The Ethics of Using QI Methods to Improve Health Care Quality and Safety

The Ethics of Using QI Methods to Improve Health Care Quality and Safety Mary Ann Baily (bio), Melissa Bottrell (bio), Joanne Lynn (bio), and Bruce Jennings (bio) PROJECT PARTICIPANTS Organizational affiliations for identification purposes only; affiliations current as of 2006 George J. Agich, PhD Bowling Green State University Bowling Green, OH Mary Ann Baily, PhD The Hastings Center Garrison, NY Paul Batalden, MD Dartmouth Medical School Hanover, NH Nancy Berlinger, PhD, MDiv The Hastings Center Garrison, NY *Melissa Bottrell, MPH, PhD National Center for Ethics in Health Care, Veterans Health Administration Seattle, WA *Michael Carome, MD DHHS Office for Human Research Protections Rockville, MD David Casarett, MD, MA Center for Health Equity Research and Promotion Philadelphia VA Medical Center Philadelphia, PA Janet Corrigan, PhD National Quality Forum Washington, DC Linda Cronenwett, PhD, RN, FAAN University of North Carolina at Chapel Hill, School of Nursing Chapel Hill, NC Frank Davidoff, MD, MACP Institute for Healthcare Improvement Wethersfield, CT Nancy Neveloff Dubler, LLB Montefiore Medical Center Bronx, NY *Arnold Farley, PhD Centers for Medicare and Medicaid Services Baltimore, MD *J. Michael Fitzmaurice, PhD Agency for Healthcare Research and Quality Rockville, MD *Ellen Fox, MD National Center for Ethics in Health Care, Veterans Health Administration Washington, DC Brent James, MD, MSTAT Intermountain Institute for Health Care Delivery Research Salt Lake City, UT *Stephen F. Jencks, MD, MPH Centers for Medicare and Medicaid Services Baltimore, MD Bruce Jennings, MA Center for Humans and Nature New York, NY Robert J. Levine, MD Yale University New Haven, CT Joanne Lynn, MD, MA, MS The RAND Corporation Arlington, VA Karen Maschke, PhD The Hastings Center Garrison, NY Ethel Mitty, EdD, RN New York University College of Nursing New York, NY Robyn Y. Nishimi, PhD National Quality Forum Washington, DC Margaret O'Kane, MHA National Committee for Quality Assurance Washington, DC Paul Schyve, MD Joint Commission on Accreditation of Healthcare Organizations Oakbrook Terrace, IL Theodore Speroff, PhD Vanderbilt University Medical Center Nashville, TN Sean Tunis, MD, MSc HealthTech San Francisco, CA Matthew K. Wynia, MD, MPH American Medical Association Institute for Ethics Chicago, IL *Note: The authors of this report are responsible for its content. Statements in this report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S Department of Health and Human Services. The federal government employees listed above participated in the meeting discussions in an advisory capacity. However, in addition to the preceding disclaimer, it should be further emphasized that the statements in this report should not be construed as endorsement by the Department of Veterans Affairs or any other department of the U.S. government, nor do they represent the policies of any federal departments, agencies, or offiices. End Page S2 Preface Powerful forces of change are at work within the American health care system. The public debate concerning health care financing and access to insurance coverage is intensifying. But below the surface of the media and policy debate about cost and access, a quieter but perhaps more significant process of change is under way: the transformation of health care management and delivery-indeed, health professional work itself-through health care quality improvement. The innovative, interdisciplinary quality improvement (QI) movement has begun to significantly upgrade delivery of health care in the United States. Taking its cue from reform approaches in other industries, and driven especially by studies indicating a shockingly widespread incidence of medical errors and a striking lack of consistency in the standard of care patients receive in different facilities and from different practitioners, the QI movement has arrived in health care. Using knowledge gained from the disciplines of medicine, nursing, health care management, and medical and health services research, it attempts to mobilize people within the health care system to work together in a systematic way to improve the care they provide. In this work, discipline-specific knowledge is combined with experiential learning and discovery to make improvements. Ethical issues arise in QI because attempts to improve the quality of care for some patients may sometimes inadvertently cause harm, or may benefit some at the expense of others, or may waste scarce health care resources. Ethical issues also arise because some activities aimed at...