Injecting Ethics into the Public Health Quality Improvement / Accreditation Movement

1. 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, CPHHealth Officer, Clark, Cowlitz, Skamania, and Wahkiakum Counties

2. Overview • Case Example • Public Health Code of Ethics • Crosswalk of Public Health Accreditation and the Public Health Code of Ethics • Discussion

3. Case Study: Water Supply • Environmental factors • Testing results • Studies • Health Effects

4. 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?

5. 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?

6. Poll 1 Would you act any differently if a different water source at a high price could supply your city? Yes No

7. 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

8. Linking Accreditation Process & Core Values AccreditationOpportunity for health departments to learn and incorporate quality and performance improvement techniques Quality ImprovementTechniques 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

9. 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

10. Linking Accreditation and Core Values Lessons 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

11. The Seven Factors of Excellence Leadership & Employee Orientation Response to External Change Innovation Vision Mission Core Values ) Customer & Client Orientation Quality (Accreditation) Teamwork From Duncan & Ginter

12. Legal Issues Public Health Context Public Health Activities and Policies Public Health EthicsIssues

13. 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).

14. Definitions and Concepts

15. 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

16. Administrative Discretion Under the Law TB Outbreak in a Community • Law • Authority to detain individuals who are non-compliant with the TB treatment regimen • 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…”

17. 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

18. 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

19. 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

20. 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

21. Role of the Code in Accreditation • Principles can be applied in different areas of public health practiceExamples: disease control and public health genomics • Principles are compatible with movements to accredit particular programsExample: accrediting public health research ethics review

22. 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

23. Standard Domains • Monitor health status and understand health issues. • Protect people from health problems and health hazards. • Give people information they need to make healthy choices. • Engage the community to identify and solve health problems. • Develop public health policies and plans. • Enforce public health laws and regulations. • Help people receive health services. • Maintain a competent public health workforce. • Use continuous quality improvement tools to evaluate and improve the quality of programs and interventions. • Contribute to and apply the evidence base of public health. • Govern and manage health department resources (including financial and human resources, facilities, and information systems).

24. The Public Health Code of Ethics Principles of the Ethical Practice of Public Health* 1 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 2 3 4 * Principles of the Ethical Practice of Public Health, The Public Health Leadership Society (2002), http://www.phls.org

25. 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 5 6 7 8

26. 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 9 10 11 12