Guidelines For The Ethics Committee

I. PREAMBLE

Five fundamental values form the foundation of the Cleveland Clinic (CCF) culture: quality, integrity, compassion, collaboration, and commitment.

II. MISSION

The CCF Ethics Committee will be a proactive resource supporting and promoting the five fundamental values, and the ethical conduct and decisions of CCF's professionals, administrators, employees, patients and their families.

III. VISION

The CCF Ethics Committee will be available to:

1. Serve to clarify practical applications of the five fundamental values in all aspects of patient care and in the management practices that affect patient care.

2. Recommend and review clinical, human-resource and business-related ethics policies and procedures that guide professional and administrative responsibilities.

3. Recommend and review policies and procedures related to patients' rights and responsibilities.

4. Monitor outcomes intended by CCF's ethics policies and procedures.

5. Provide ethics case consultation when requested, or when issues arising in a specific case have institutional or organizational ramifications.

6. Review concerns regarding violations of the CCF Code of Ethical Business and Professional Behavior, and make related recommendations to the Board of Governors.

7. Support the educational efforts of the Department of Bioethics, and evaluate the impact of these efforts on policy implementation.

IV. REPORTING AND ORGANIZATIONAL RELATIONSHIPS

1. The CCF Ethics Committee reports to the Board of Governors.

2. The CCF Ethics Committee is a review committee as described in Section 2305.25 of the Ohio Revised Code, with the members accordingly entitled to the protections afforded by Section 2305.24 - 2305.251 of the Ohio Revised Code.

3. When appropriate, the Ethics Committee will work and consult with other CCF administrative departments and committees (e.g., Department of Bioethics, Office of Quality Management, and the Institutional Review Board).

V. MEMBERSHIP

A. General

1. The CCF Ethics Committee will have multi-disciplinary representation with sufficient diversity to achieve its mission and vision, and as determined by the Board of Governors.

2. Members of the Staff or outside consultants may be called upon to assist and advise the Ethics Committee when circumstances indicate their expertise is needed.

3. When the need for new members arises, candidates for membership will be submitted by the Ethics Committee to the Board of Governors for appointment.

4. Members are appointed by the Board of Governors for three-year terms, staggered as evenly as possible, and limited to two consecutive terms. The Ethics Committee should always retain representation from the Department of Bioethics and from the Office of General Counsel.

5. Each member is expected to attend two-thirds of regularly scheduled meetings. On a semi-annual basis, the Chair of the Ethics Committee will contact members not meeting this attendance standard to ascertain their availability for continued service on the Ethics Committee.

6. New members will receive formal bioethics education and training. Throughout the year, all members should demonstrate some evidence of continuing ethics education.

B. Officers

1. The Chair of the Ethics Committee will be a full-time Professional Staff physician appointed (or re-appointed) by the Board of Governors annually. The Chair is responsible for the overall administrative functioning of the Committee, and presides over all meetings.

2. The Vice-Chair of the Ethics Committee will be appointed (or re-appointed) by the Chair and approved by the Board of Governors annually. The Vice-Chair will assume the responsibilities of the Chair in his/her absence.

3. The Board of Governors will determine the term of office for the Chair and Vice-Chair. 4. The Chair or his/her designate will represent the CCF Ethics Committee at the meetings of the Ethics Council of the Cleveland Clinic Health System.

VI. PROCEDURES

A. Meetings

1. The Ethics Committee will meet monthly. 2. A majority of members must be present to conduct the business of the Ethics Committee.

B. Access

1. Access to the Ethics Committee for consultation is available to all patients, their families, and all CCF employees.

2. Consultations by the Ethics Committee should take place if the individual(s) seeking assistance explicitly request an Ethics Committee consultation or, if the needs of the requester cannot or are not met by the Department of Bioethics.

C. Consultation Protocol - See Ethics Consultation Policy

VII. COMMITTEE ASSESSMENT AND EVALUATION

1. A satisfaction survey will be completed annually by Ethics Committee members concerning the meetings and the performance of the Chair and Vice-chair.

2. A satisfaction survey will be sent to participants of Ethics Committee consultations (i.e., patients, family members, CCF professionals, and Ethics Committee members) for review, assessment and quality improvement.

3. An annual report of the Ethics Committee' s activities will be submitted to the Office of the Chief of Staff who will submit the report to the Board of Governors.

ECRevisedBylawsguidelines7/2001

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