Social Work Ethics Audits in Health Care Settings: A Case Study

PRACTICE FORUM

Social Work Ethics Audits in Health Care Settings: A Case Study

William J. Kirkpatrick, Frederic G. Reamer, and Marilyn Sykulski

In recent years social workers in health care set-tings have paid increased attention to ethicalissues and decision making. Along with mem- bers of allied health professions, social workers have enhanced their understanding of ethical challenges related to organ transplantation, the use of artificial organs, end-of-life decisions, genetic engineering, aggressive treatment of seriously impaired infants and frail elders, abortion, managed care, and the protection of participants in research protocols (Congress, 1998; Foster, 1995; Loewenberg & DolgofF, 1996; Reamer, 1985, 2006).

Most recently, various health care professions have begun to recognize the relevance of ethics “risk management” (Cohen-Almagor, 2000; Reamer, 2001a). Risk management is a concept that emerged in the 1960s; originally, the concept referred to efforts to minimize business-related losses resulting from accidents, theft, and negligence (Vaughan &Vaughan, 2000). Over time, risk man- agement has broadened in scope to include many other settings and contexts, including various health professions. A broad range of health agencies now pay considerable attention to steps they can take to minimize the likehhood of harm to clients and staff, prevent ethics complaints (filed with profes- sional associations and state licensing and regula- tory boards), and prevent lawsuits alleging some form of ethics-related neghgence (for example, conflicts of interest, inappropriate dual relationships or boundary violations, unethical delivery of ser- vices, mishandling of confidential information, and unethical termination of services (Barker & Branson, 2000; Houston-Vega & Nuehring, 1997; Reamer, 1998, 2003; Strom-Gottfried, 1999).

This article describes a practical strategy—the Social Work Ethics Audit—that promotes ethical practice in health settings and minimizes ethics- related risks.

THE SOCIAL WORK ETHICS AUDIT The Social Work Ethics Audit (SWEA) (Reamer, 2001b) provides social workers and their agencies with an easy-to-use tool to examine their ethics- related practices, policies, and procedures; ensure quality; and promote ethics-related risk manage- ment. SWEA provides social workers with a tool to help them identify pertinent ethical issues in their practice settings, review and assess the adequacy of their current practices, design a practical strategy to modify current practices as needed, and monitor the implementation of this quality assurance strat- egy. The audit is especially useful to administrators whose agencies seek accreditation and to supervi- sors who want to structure their ethics-related dis- cussions with supervisees.

SWEA includes a structured instrument and protocol that facilitate this comprehensive assess- ment. The audit focuses on specific ethical risks found in human services settings: client rights, con- fidentiality and privacy, informed consent, high- risk interventions, boundary issues, conflicts of in- terest, documentation, defamation of character, client records, supervision, staff development and training, consultation and referral, fraud, termina- tion of services, practitioner impairment, and evalu- ation and research.

The ethics audit involves six key steps: (1) form an audit committee; (2) using the topical outline, identify specific ethics-related issues on which to focus; (3) gather forms, policies, regulations, and other documents required for the audit; (4) assess multiple topics in 16 discrete risk areas and assign a score on a four-point scale indicating no risk, mini- mal risk, moderate risk, or high risk; (5) develop a comprehensive, detailed “action plan” for each risk area that warrants attention, starting with high-risk areas; and (6) establish a mechanism to follow up on each task to ensure its completion and monitor

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its implementation. (SWEA is accompanied by a computer disk that facilitates the audit process.)

The assessment of each risk area is divided into two sections: policies and procedures. Relevant agency policies may be codified in formal agency documents or memorandums (for example, policy concerning confidentiality, informed consent, conflicts of interest, termination of services). Pro- cedures entail social workers’ actual handling of ethical issues and dilemmas.

An ethics audit was conducted in 2001—2002 at three health care settings that are part of a large hospital corporation affiliated with a medical school: (1) a large urban, tertiary care hospital (719 beds and 25 MSWs), (2) a community hospital (247 beds and 4 MSWs), and (3) a child and adolescent psy- chiatric hospital (60 beds and 17 MSWs) .The audit committee included the social work director and managers of the three sites.The social work direc- tor and managers reviewed numerous social work and hospital policy manuals related to delivery of services, human resources, medical records, and re- search. The director and managers also met with social work staffers to discuss diverse ethics-related risks. During the discussion, social workers raised a number of compelling ethical challenges. For ex- ample, one social worker expressed feeling at high risk in the area of nontraditional interventions and described a situation in which a patient specifically requested that the social worker not reveal her use of herbal therapy to the physician for fear of rejec- tion or disapproval.Another social worker disclosed that she discovered two file drawers of notes and “shadow” records that had been maintained by a former social worker who had worked with pa- tients in the early days of HIV/AIDS. The former social worker had been concerned about placing certain information about patients’ HIV status in the official medical record, fearing that this sensi- tive information would be accessible by others. Maintaining a separate file addressed this need at that time, but over time the files were forgotten about.

Although the results among the three hospitals differed, the overall pattern was similar. Relatively few ethical issues were considered high risk (5 per- cent) or moderate risk (7 percent). A larger number were considered minimal risk (20 percent) and about two-thirds were assessed as no risk (67 percent). The most significant risks were related to policies and procedures concerning informed consent (for

example, providing interpreter and translation ser- vices for non-English-speaking patients); handling of confidential information (for example, disclo- sure of a patient’s substance abuse history to hospi- tal staff without patient consent; disclosure of sen- sitive information to managed care organizations); maintenance of proper boundaries with patients (for example, developing friendships with patients); patients’ use of nontraditional interventions (for example, patients’ use of herbal remedies); supervi- sion of staff (for example, frequency, quality, and documentation of supervision); staff consultation (for example, when and how to obtain consulta- tion); screening of community-based specialists for patient referral; monitoring the quality of care provided by community-based providers; and docu- menting ethical decisions.

Analysis of the audit results revealed four pat- terns or permutations with regard to ethics-related pohcies and procedures relevant to social work: (1) strong policies and strong procedures, (2) strong policies and weak procedures, (3) weak policies and strong procedures, and (4) weak policies and weak procedures.The audit tool calls for development of a detailed action plan for each ethics audit topic that especially warrants attention (moderate- and high-risk items in categories 2 through 4). Because the audit was conducted at three sites, some ele- ments of the action plan were similar across institu- tions and some varied.

Social work directors and managers identified a number of areas where existing policies were not consistent with hospital policies or prevailing so- cial work ethics standards. During a meeting to discuss audit results, staff also identified areas where policies needed to be created or revised signifi- cantly and substantive areas where staff training was needed. After the debriefing session the commit- tee formulated specific action steps. The first goal was to focus on the audit topics that were rated as moderate- and high-risk areas. For example, al- though supervision is well understood by the pro- fession of social work and integrated into depart- mental activity, it is not well understood among other hospital staff. As the literature suggests, eth- ics complaints and lawsuits involving social work- ers sometimes claim that flawed supervision con- tributed to the ethics-related negligence (Houston-Vega & Nuehring, 1997; Reamer, 2003). Even though the staff rated the practice of supervision as strong, the lack of a clear policy on

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supervision (for example, format, frequency, and documentation) resulted in this section on policy being rated as high risk. Therefore a new pohcy defining the purpose, functions, and parameters of supervision was created. Another policy was writ- ten to address some of the other areas of moderate and high risk in terms of policy, for example, boundaries and conflicts of interest.This new policy is based on guidelines in the NASW Code of Ethics (2000). (Figure 1 summarizes the comprehensive action plan.)

IMPLICATIONS FOR PRACTICE The primary purpose of the ethics audit conducted in social work departments in three different hos- pitals was to assess the adequacy of practitioners’ and administrators’ ethics-related policies and pro- cedures.The audit identified a number of key areas where hospital social workers needed to revise ex- isting policies and procedures or create new poli- cies.The audit process provided administrators and staff with a valuable, productive opportunity to examine their policies and practices, identify risk areas, and develop an assertive and constructive strategy to enhance their handling of ethical issues.

During the audit process, the audit committee quickly discovered that it would need to distin- guish between ethical issues that were unique to the social work departments—and over which the auditors have considerable control—and ethical is- sues that involve other hospital departments. For example, social work departments can assess and, where necessary, modify the procedures its staff members use to screen community-based referrals and maintain proper boundaries with patients and former patients. However, social work auditors may have less control over hospitalwide policies and procedures related to the documentation of inter-

departmental consultation, potential confiicts of interest among staff in various hospital departments, and the division of responsibility among depart- ments for revision of informed consent documents and procedures.

This feature of hospital-based social work dis- tinguishes it from social work practiced in a variety of other settings where the profession has more autonomy. For example, social workers who con- duct an ethics audit in a family services agency or mental health center may be able to exercise more autonomy and control over the audit process and the action steps that are warranted once the audit is completed. In light of this important distinction, social workers in hospital settings would be wise to keep several lessons in mind as they embark on an ethics audit:

• Social workers should involve key represen- tatives of all relevant hospital departments (for example, nursing, risk management, and le- gal) in the design and implementation of the ethics audit. Early and active involvement in the process can enhance hospital staff mem- bers’ investment in the audit results.

• The audit committee should look for ways to draw on the results of the ethics audit to make constructive changes within the social w ôrk department and elsewhere in the hos- pital. Efforts to make changes in other hospi- tal departments should be pursued with keen awareness of relevant organizational dynam- ics, interdepartmental relationships, and po- litical considerations.

• The audit committee can sponsor educational events within the hospital to publicize its find- ings and enhance staff awareness of pertinent ethical issues. For example, once this audit

Figure 1: Comprehensive Systemwide Action Plan Revise or create policies based onjresults of audit (for example, confidentiality, supervision, boundaries, and conflicts of interest).

Add ethics audit follow-up to monthly stafF meeting agenda, and report progress in minutes.

Include specific action items from audit in manager’s annual performance goals.

Include results, actions, and follow-up in departmental annual report.

OfFer audit process as an in-service for other departments, grand rounds, articles in hospital newsletters, and so forth.

Use as preparation for the Joint Commission on Accreditation of Healthcare Organizations survey and Health Insurance Portability and Accountability Act compliance efforts.

Present audit results and actions to the hospital Ethics Committee and to the Risk Management Department.

Use in design of future educational and staff development programs (CEU programs).

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process was completed, the audit committee sponsored hospitaiwide ethics grand rounds to address a wide range of issues concerning professional boundaries and conflicts of in- terest within the hospital. Continuing edu- cation credits were offered as an incentive for staff to attend (the audience was “standing room only”).

• The audit committee must decide whether to have individual staff complete the audit instrument and then collate all ofthe results or, instead, gather all of the pertinent infor- mation from staff—through interviews, fo- cus groups, or surveys—and review hospital documents to assign risk levels for each eth- ics topic. Both approaches are defensible. Having staffers complete the audit instrument individually is labor intensive and challeng- ing logistically; however, this approach can yield valuable detailed assessments from those practitioners who encounter ethical issues daily.

• The audit committee must decide whether to conduct the audit itself, using hospital staff and resources, or retain an outside consult- ant. Use of an outside consultant can enhance neutrality and defuse the organizational poli- tics that can dilute the effect of an audit. However, this strategy can add expenses and logistical steps.

• Conducting an ethics audit provides social work departments with visibility in their host settings and an opportunity to assert leader- ship with respect to ethical issues. In addition to the substantive insights and changes that the audit can produce, the process can help showcase social work’s commitment to pro- fessional ethics and ability to enhance their agencies’ efforts to address ethical issues.

The health care professions, as a group, have be- come much more aware of ethical issues that are germane to practice.What was once fairly superfi- cial acknowledgment of ethical issues in health care has evolved into much more ambitious attempts to identify and address a wide range of issues related to ethical dilemmas, ethical decision making, and ethics-related risk management. By virtue of their generaiist approach to practice, social workers in health care settings are in a unique position to con- duct comprehensive assessments of ethical issues

related to individual patients, families, staff, and employing organizations. Ultimately, such efforts can help health care organizations fulfill their com- mitment to helping people in need,

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Cohen-Almagor, R. (Ed.). (2000). Medical ethics at the dawn ofthe 21st century. NewYork: NewYork Academy of Sciences.

Congress, E. P. (1998). Social work values and ethics: Identifying and resolving professional dilemmas. Chicago: Nelson-Hall.

Foster, L.W. (1995). Bioethicat issues. In R. L. Edwards (Ed.-in-Chief), Encyclopedia of social work (19th ed.. Vol. 1, pp. 292-298).Washington, DC: NASW Press.

Houston-Vega, M. K., & Nuehring, E. M. (with Daguio, E. R.). (1997). Prudent practice: A guide for managing malpractice risk. Washington, DC: NASW Press.

Loewenberg, F. M., & Dolgoff, R. (1996). Ethical decisions for social work practice (5th ed.). Itasca, IL: F. E. Peacock.

National Association of Social Workers. (2000). Code of ethics ofthe National Association of Social Workers. Washington, DC: Author.

Reamer, F. G. (1985).The emergence of bioethics in social work. Health & Social Work, 10, 271-281.

Reamer, F G. (1998). Ethical standards in social work:A review ofthe NASW code of ethics. Washington, DC: NASW Press.

Reamer, F. G. (2001a). Ethics education in social work. Alexandria, VA: Council on Social Work Education.

Reamer, F. G. (2001b). The social work ethics audit:A risk management tool. Washington, DC: NASW Press.

Reamer, F. G. (2003). Social work malpractice and liabiUty (2nd ed.). NewYork: Columbia University Press.

Reamer, F. G. (2006). Social work values and ethics (3rd ed.). NewYork: Columbia University Press.

Strom-Gottfried, K. (1999). Professional boundaries: An analysis of violations by social workers. Families in Society, 80, 439-449.

Vaughan, E. J., &Vaughan,T. M. (2000). Essentials of risk management and insurance (2nd ed.). New York: John Wiley & Sons.

William J. Kirkpatrick, AfSWf is director. Department of Clinical Social Work, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903; e-mail: u’kirkpat@ lifespan.org. Frederic G. Reamer, PhD, is professor. School of Social Work, Rhode Island College, Providence. Marilyn Sykulski, MSVi{LICSlif is manager, clinical social work, Emma Pendleton Bradley Hospital, East Providence, Rl.An earlier version of this article was presented at the 37th annual meeting and conference ofthe Society for Social Work Leadership in Health Care, April 2002, Albuquerque, NM.

Original manuscript received January 2, 2003 Final revision received September 10, 2003 Accepted October 28. 2003

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