Ethics in geriatric long-term care - can ethics be managed?

Quality management (QM) and quality management systems (QMS) are also important topics in nursing care for the elderly. The circulating approaches and certifiable models are based on the standards of the ISO 9001 series, on the concept of the European Foundation of Quality Management (EFQM) or on the specifications of the Cooperation for Transparency and Quality in Health Care (KTQ). In nursing homes for the elderly, systems according to ISO 9001 are widespread, as this series of standards offers the possibility of mapping all areas of responsibility of the company at process level. In the sense of a "learning organisation", all processes and documents must therefore be regularly checked for correctness, relevance and conformity to standards. Furthermore, audits also help to identify possible weaknesses and potential for improvement.

Conflicts with ethics

Organized ethics and QM have completely different functions, perspectives and starting points in a nursing home - nevertheless both are important strategies which will gain in importance in the future.

A well-functioning QMS includes clear structures and comprehensible, documented procedures as well as mechanisms for quality assurance, measurement and improvement. Here, it is not uncommon for there to be a conflict with the processes and demands of organized ethics: while a QMS is geared towards the efficient running of processes, ethical discourses and interventions usually mean an interruption and deceleration of everyday routines.

On the other hand, ethicists complain that ethics is only a label that is used in the phase of QM certification or for marketing purposes, but otherwise leads a meaningless, powerless existence.

It should be noted that ethics does not only have to be a "victim" of ignorance, but can also be partly responsible for this misery. The distrust may in fact also be mutual: ethicists mostly view the implementation in a QMS critically, as the manifestation of processes within ethics organizations is perceived as constricting. The tools of the QMS evoke a "bureaucratic scepticism".

Heinemann (2010) emphasises that in addition to a general scepticism and fear, an "organisational naivety of ethics" can arise, which underestimates the potential of an integration into a management system. Here, on the part of ethics, it is not recognized that it needs to learn the language of the organization in order to gain importance in the organization. After all, ethics can also benefit from the QMS: The use of certified QM systems is partly responsible for the fact that institutionalized ethical discourse in health care has developed strongly in recent years.

The certifications, above all according to the KTQ and "pro- Cum Cert (pCC) systems, explicitly ask for the existence of an ethics organisation and honour this in the assessment. This circumstance has further supported and promoted the spread of ethics consulting.

Open questions

It is therefore worthwhile, if not necessary, to reflect more closely on the connection between the two "parallel universes". From a practical point of view, the following questions arise:

• How can the ethics organization be integrated and adequately weighted in a QM process model?
• How can processes within the ethics organisation be standardised and structured without losing their necessary flexibility?
• Which working tools and documents are needed for this?
• How can employees participate in the ethics organization and what access must be provided?
• How can decisions, recommendations and ethical guidelines be communicated in an appropriate, transparent and comprehensible way?
• How can QM contribute to making the performance of the ethics organisation systematically measurable and evaluable?

There are hardly any examples in the literature of how the "QM" and "ethics" systems could be synchronized to function equally successfully. The Mattenhof and Irchelpark care centres in the city of Zurich set a good example.

Note: Part 2 of this thesis deals with the daily, concrete implementation of ethics and quality management in the practice of the Mattenhof and Irchelpark nursing centres.