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Preventing ethics conflicts and improving healthcare quality through system redesign
  1. William A Nelson1,
  2. Paul B Gardent1,2,
  3. Eliza Shulman3,
  4. Mark E Splaine1
  1. 1Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, Hew Hampshire, USA
  2. 2Tuck School of Business at Dartmouth, Hanover, New Hampshire, USA
  3. 3Department of Family Medicine, Harvard Vanguard Medical Associates; Clinical Instructor, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to William A Nelson, Dartmouth Medical School – HB 7250, The Dartmouth Institute for Health Policy and Clinical Practice, 46 Centerra Parkway, Lebanon, NH 03766, USA; william.a.nelson{at}


Background Ethics and quality care are common drivers for healthcare organisations. Both are based on ethics principles that are the foundation for quality, and are synergistic with the Institute of Medicine's six quality aims. This paper describes the relationship between ethics principles and the goals of improving quality, safety and value. It demonstrates how healthcare staff, quality improvement professionals and ethics committee members could apply a quality improvement framework to address and prevent ethics issues.

Discussion Recurring ethics issues can have a detrimental impact on both the quality of patient care and the culture of a healthcare organisation. Clinical staff and ethics committee members traditionally respond to ethics issues using a reactive approach. Despite nascent interest in a system-oriented preventive approach to ethics issues, there is limited practical advice for ethics committee members regarding how to specifically implement a system redesign strategy. Using an illustrative case study, the authors demonstrate how to apply a recognised quality improvement framework, which focuses on clinical microsystems, to manage and decrease ethics issues—therefore enhancing the organisation's quality of care.

Conclusion An important step in enhancing quality and ethics aims would be for the organisation's staff, including quality improvement professionals and ethics committee members, to collaborate in fostering system redesign. The authors' aim is not to examine in detail a specific quality improvement approach or method; rather, they wish to highlight the synergy they believe exists between quality improvement efforts and organisational ethics issues.

  • Healthcare ethics
  • quality improvement
  • clinical microsystems
  • ethics committees
  • bioethics
  • clinical practice guidelines
  • healthcare quality improvement
  • microsystem
  • quality of care

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  • See Commentary, p 473

  • Linked articles 048819, 033530.

  • Funding Dr. Nelson is supported in part by the Veterans Engineering Resource Center (VERC), New England Healthcare Engineering Partnership. Dr. Splaine is supported in part by the VA National Quality Scholars Fellowship Program. The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or of the United States government.

  • Competing interests None declared.

  • Ethics approval This manuscript did not involve human subject research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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