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Social work ethics audits in health care settings: a case study.

In recent years social workers in health care settings have paid increased attention to ethical issues and decision making. Along with members 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 management 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 likelihood of harm to clients and staff, prevent ethics complaints (filed with professional associations and state licensing and regulatory boards), and prevent lawsuits alleging some form of ethics-related negligence (for example, conflicts of interest, inappropriate dual relationships or boundary violations, unethical delivery of services, 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 management. 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 strategy. The audit is especially useful to administrators whose agencies seek accreditation and to supervisors who want to structure their ethics-related discussions with supervisees. SWEA includes a structured instrument and protocol that facilitate this comprehensive assessment. The audit focuses on specific ethical risks found in human services settings: client rights, confidentiality and privacy, informed consent, high-risk interventions, boundary issues, conflicts of interest, documentation, defamation of character, client records, supervision, staff development and training, consultation and referral, fraud, termination of services, practitioner impairment, and evaluation 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, minimal 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 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. …