Richard J. Nance, MSHHA, MSW, LCSW, Director
Utah County Department of Drug and Alcohol
Prevention and Treatment
Ethical
Standards
and Practices
for Clinicians
Three Steps to Systematic
Management of Ethical Issues
in MH/SUD Agencies
Speaker Name
Title
Organization
Organization of This Presentation
• Justification for MH/SUD Provider Agencies
to Have a Code of Ethics/Conduct That
Applies to the Entire Agency
• Process to Develop an Agency Code of
Ethics/Conduct
• Tool to Evaluate Ethical Situations (either
potential or actual)
Council on Accreditation
Standards Relative to Ethics
Behavioral Health Accreditation Standards
• PA-ETH 5.01
– Personnel know and follow the code of ethics of their
respective professions.
CARF Standards Relative to Ethics
Behavioral Health Business Practices:
•
Section 1: Standard 3: Corporate responsibility efforts include, at a minimum, the
following:
– Written ethical codes of conduct in at least the following areas:
• Business
• Marketing
• Service Delivery
• Professional Responsibilities
• Human Resources
– Written procedures to deal with allegations of violations of ethical codes
– Policies to educate personnel and other stakeholders on ethical codes of
conduct
– Policies and written procedures on waste, fraud, abuse, and other wrong doing
that include:
• A no reprisal approach for personnel reporting
• Time frames for investigation
– Advocacy efforts for the persons served
– Policies on contractual relationships
– Demonstrated corporate citizenship
JCAHO Standards Relative to Ethics
JCAHO Standards relative to ethics are found
in the Human Resource Management
section, but primarily in the Leadership
section of the Behavioral Health Standards
JCAHO Standards Relative to Ethics
Chapter: Human Resources Management
HRM.01.03.01: The organization provides orientation to staff.
6.
The organization orients staff on the following: The rights of individuals served,
including the ethical aspects of care, treatment, or services. Completion of this
orientation is documented. (See also RI.01.07.03, EP 5)
HRM.01.06.03: Staff who assess individuals with substance abuse, dependence,
and other addictive behaviors and who plan services for and deliver services to
these individuals have specific competencies.
2.
Staff who assess individuals with substance abuse, dependence, and other
addictive behaviors and who plan services for and deliver services to these
individuals have the knowledge and skills to do the following:
- Demonstrate adherence to accepted ethical and behavioral standards of
conduct
JCAHO HRM Stds (cont’d)
HRM.01.06.03: Staff who assess individuals with
substance abuse, dependence, and other addictive
behaviors and who plan services for and deliver services
to these individuals have specific competencies.
2.
Staff who assess individuals with substance abuse,
dependence, and other addictive behaviors and who plan
services for and deliver services to these individuals have
the knowledge and skills to do the following:
- Demonstrate adherence to accepted ethical and behavioral
standards of conduct
JCAHO Leadership Standards
Chapter: Leadership
Overview:
The safety and quality of care, treatment, or services depend on many factors,
including the following:
- A culture that fosters safety as a priority for everyone who works in the
organization
- The planning and provision of services that meet the needs of individuals served
- The availability of resources—human, financial, and physical—for providing
care, treatment, or services
- The existence of competent staff and other care providers
- Ongoing evaluation of and improvement in performance
•
Leaders shape the organization’s culture, and the culture, in turn, affects how
the organization accomplishes its work…. Leaders must ask some basic
questions in order to provide this focus… By what ethical standards will the
organization operate?
JCAHO Leadership (cont’d)
• Chapter: Leadership
Found throughout this section: “Leaders establish the
ethical framework in which the organization operates,
create policies and procedures, and secure resources
and services that support client safety and quality care,
treatment, or services.”
LD.04.01.01: The organization complies with law and regulation.
LD.04.01.03: The organization develops an annual operating budget and,
when needed, a long term capital expenditure plan.
LD.04.01.05: The organization effectively manages its programs or
services.
LD.04.01.11: The organization makes space and equipment available as
needed for the provision of care, treatment, or services.
JCAHO Leadership (cont’d)
LD.04.02.01: The leaders address any conflict of interest involving staff
that affects or has the potential to affect the safety or quality of care,
treatment, or services. (Conflicts of Interest)
CORPORATE COMPLIANCE IS A DIFFERENT ISSUE ALTOGETHER!
JCAHO Leadership (cont’d)
LD.04.02.03: Ethical principles guide the organization’s business
practices.
Although some leaders may not be involved in the day to day, hands on
operations of the organization, their decisions and work affect, either
directly or indirectly, every aspect of operations. They are the driving
force behind the culture of the organization. Leaders establish the
ethical framework in which the organization operates, create policies
and procedures, and secure resources and services that support
client safety and quality care, treatment, or services. Policies,
procedures, resources, and services are all influenced by the culture
of the organization and, in turn, influence the culture.
Elements of Performance
1.
The organization has a process that allows staff, individuals served, and families to
address ethical issues or issues prone to conflict.
2.
The organization uses its process to address ethical issues or issues prone to
conflict. ……
JCAHO Leadership (cont’d)
LD.04.02.05: When internal or external review results in the denial of care,
treatment, or services, or payment, the organization makes decisions
regarding the ongoing provision of care, treatment, or services, and
discharge or transfer, based on the assessed needs of the individual
served.
LD.04.03.01: The organization provides services that meet needs of the
individual served.
LD.04.03.05: Services are defined through the collaboration of the
organization’s leaders with leaders of the various communities served
by the organization and other external organizations.
LD.04.03.07: Individuals with comparable needs receive the same
standard of care, treatment, or services throughout the organization.
LD.04.03.09: Care, treatment, or services provided through contractual
agreement are provided safely and effectively.
LD.04.04.01: Leaders establish priorities for performance improvement.
Other Accrediting Bodies
• Accreditation Association for Ambulatory Health
Care (AAAHC)
• Accreditation Commission for Health Care (ACHC)
• Board of Certification/Accreditation, International (BOC)
• Center for Improvement in Healthcare Quality (CIHQ)[1]
• Utilization Review Accreditation Commission (URAC)
• Healthcare Facilities Accreditation Program (HFAP)
• Healthcare Quality Association on Accreditation (HQAA)
• The Joint Commission (TJC)
• National Committee for Quality Assurance (NCQA)
Process to Develop an Agency
Code of Ethics/Conduct
Developing an Agency Code of Ethics or
Professional Practice
“A code of Professional Practice is a defined
set of beliefs, values and standards that
guide organization members in the conduct of
activities in pursuit of the agency’s mission….
The Code defines boundaries of appropriate
and inappropriate conduct. (It) sets forth
guidelines to be used by staff to guide them
through difficult and complex situations
encountered in the performance of their
roles.” (White and Popovits)
Texts Used to Prepare
This Presentation
Content
Unethical acts committed by therapists in descending order of
frequency include:
• Sexual Exploitation
• Dual Relationships
• Boundary Violations
• Breach of confidentiality/refusal to provide records
• Fraudulent billing
• Financial Exploitation of a client
• Provision of services while impaired
• Violation of reporting statutes (child abuse)
• Other miscellaneous acts (practice on suspended revoked
license)
(Hartsell and Bernstein)
Steps to Develop a Code of Professional
Practice or Agency Ethics
White and Popovits recommend a comprehensive
process:
1. Preliminary Discussion and Needs Assessment
(pg 18)
2. All Staff Orientation to Purpose and Steps to
Develop
3. Select a multidisciplinary ad hoc task force
(include staff hostile to the concept)
4. Don’t Re-Invent the Wheel – Obtain and
Circulate Sample Codes of Ethics
Reconciling Professional Ethics Codes
NASW Code of Ethics 4.07 Solicitations
• (b) Social workers should not engage in
solicitation of testimonial endorsements
(including solicitation of consent to use a
client’s prior statement as a testimonial
endorsement) from current clients or from
other people who, because of their particular
circumstances, are vulnerable to undue
influence.
(Hartsell and Bernstein)
Reconciling Professional Ethics Codes
APA Ethical Principles of Pschologists and
Code of conduct 5.05 Testimonials
• Psychologists do not solicit testimonials from
current therapy clients/patients or other
persons who because of their particular
circumstances are vulnerable to undue
influence.
(Hartsell and Bernstein)
Reconciling Professional Ethics Codes
American Counseling Association Code of
Ethics C.3.b. Testimonials
• Counselors who use testimonials do not
solicit them from current clients nor former
clients, nor any other persons who may be
vulnerable to undue influence.
(Hartsell and Bernstein)
Reconciling Professional Ethics Codes
NAADAC Code of Ethics
• Silent on the issue
NAATP Code of Ethics
• Exposing Clients’ Identities for Marketing Purposes
– Treatment providers will not exploit their clients’ rights to
privacy for the purpose of promoting or marketing their
programs.
– NAATP members and member organizations hold sacred
the shared value of our patients’ rights to privacy. Clients’
identities may not be revealed by a treatment provider –
neither in the form of photographic images, video images,
media coverage, nor in marketing testimonials – at any
time during the client’s engagement in treatment.
Reconciling Professional Ethics Codes
42 CFR Part 2
• §2.12 Applicability.
• (a) General—(1) Restrictions on disclosure. The
restrictions on disclosure in these regulations apply
to any information, whether or not recorded, which:
• (i) Would identify a patient as an alcohol or drug
abuser either directly, by reference to other publicly
available information, or through verification of such
an identification by another person;
(This requirement extends from the client’s first contact
with the agency requesting treatment, beyond
discharge, and beyond the death of the client.)
Steps to Develop a Code of Professional Practice
or Agency Ethics (cont’d from slide 16)
5. Multiple Small Group Meetings Are Held Using
Agency and State Examples of Ethical
Breaches to Validate Necessity.
6. Use Knowledge Gathered in Steps 4 and 5 to
Develop a Draft Code.
7. Circulate Draft to All Staff for Review and
Comment (Include Board and Legal Counsel.)
8. Task force integrates input collected from Step
7 into a final draft.
The Online Therapy Institute
Steps to Develop a Code of Professional
Practice or Agency Ethics
9. Management team, CEO and Personnel
Committee of the Board Approve the Code.
10.Integrate into Personnel Polices and
Procedures (including disciplinary policies).
11.Announce an effective Date, and Train/Orient
All Staff to the New Code of Professional
Practice.
12.All Staff Are Required to Sign a Statement That
They Have Read, Been Trained, and Pledge to
Adhere to the Code. File in Staff Personnel
Records.
Steps to Develop a Code of Professional
Practice or Agency Ethics
13. CEO and Board Establish a Mechanism for
Periodic Review and Update.
14. CPP is Integrated into New Employee Orientation
and Made a Part of Annual or Semi-annual Training
and Re-signing by Current staff.
15. Consider Publishing Your CPP and Making it a Part
of Your Organization’s Public Identity.
16. A normal time span for completing the steps to
develop a CPP can be anywhere from 12 – 24
months depending on the size of the agency and
other distractions.
Tool to Evaluate Ethical Situations
(potential or actual)
Critical Incident Review
It is wise, if not essential, to develop a process for
review and evaluation of critical ethical incidents
similar to risk management incident reporting
procedures.
• Critical Incident Review can:
– preempt actual incidents from occurring
– Be used to evaluate ethical breaches after the fact
– Serve as a basis to update or create new policies and
procedures around potential and actual violations
(These should NOT be included in client records
unless state law requires it (Iowa Incident
Reporting Regulations)
Worksheet for Critical Incidents
Identify the incident: Date, Incident Description,
Persons Involved
I. Whose interests are involved and who can be
harmed?
II. Which universal ethical values apply to this
incident?
III. What laws, standards, policies, or historical
practices should guide us in this situation?
IV. What steps should be taken to remedy the current
situation or prevent future ones?
(White and Popovits)
I. Whose Interests are Involved?
Who Can Be Harmed?
Interests and
Vulnerabilities
Client/Family
Significant Moderate
Staff Member
Agency
Professional Field
Community/Public
Safety
Which interests, if any, are in conflict?
Minimal/None
The National Council Code of Ethics
• …The interest of the person [client/family]
served is always respected…whether
individuals, families or organizations…
• …All staff shall avoid conflicts of interest and
misrepresentation of their services, credentials
or skills. They recognize accountability to the
organization [agency] and persons served with
whom they are involved and accept
responsibility for their own actions….
• …Activities shall reflect the best interest of the
general public [community, public safety]….
II. Application of Universal Values
•
•
•
•
•
•
•
•
•
Autonomy
Obedience
Conscientious Refusal
Beneficence
Gratitude
Competence
Justice
Stewardship
Honesty and Candor
•
•
•
•
•
•
•
•
•
Fidelity
Loyalty
Diligence
Discretion
Self-improvement
Nonmaleficence
Restitution
Self-interest
Other Culture Specific
Values
III. Laws, Standards, Policies,
or Historical Practices
• Some behavior may be ethical and illegal, or
unethical and legal!
• What is the standard of practice in your
community?
• What agency policies and procedures might
have been violated?
• Is there a precedent in your agency that
guides the practice but is not in policy?
IV. What steps should be taken to remedy the
current situation or prevent future ones?
Discuss the incident with your executive or risk
management team. Board involvement may be
indicated.
• Summarize the previous three parts of the critical
incident analysis.
• Should anything be done now to address the ethical
incident? Is disciplinary or other action required?
• Should policies and procedures be changed or new
ones written to govern future potential incidents?
Summary
• Mental health and substance use disorder
provider agencies are required by multiple
outside entities to have a CPP.
• Experts in the field provide guidance and
resources on how to develop and keep
current a comprehensive CPP.
• It is important to evaluate actual and potential
ethical breaches using a structured approach.
Bibliography and Contact Information
• White, W.L. and Popovits, R.M., (2001). Critical Incidents:
Ethical Issues in the Prevention and Treatment of
Addictions, Second Edition, Bloomington, IL: Lighthouse
Institute
• Hartsell,T.L., Bernstein, B.E. (2008). The Portable Ethicist
for Mental Health Professionals: A complete Guide to
Comprehensive Practice - 2nd Edition. Hoboken, NJ: John
Wiley and Sons
• Richard J. Nance, MSHHA, MSW, LCSW, Director
Utah County Department of Drug and Alcohol Prevention
and Treatment
[email protected]
801-851-7127