DDHA 8006 Week 11 Reflective Synthesis Example

Four Positions I Now Hold, Where Each One Changed and What Remains Unsettled: A Reflective Synthesis

Student Name

Walden University

DDHA 8006: Doctor of Healthcare Administration Foundational Concepts

Instructor Name

Month Day, Year

Four Positions I Now Hold, Where Each One Changed and What Remains Unsettled: A Reflective Synthesis

Purpose

This synthesis looks back on the foundational course in the DHA program through the referral inquiry I built around Tallgrass, the invented group of nine practices that carried my work all term. Rather than summarize the weeks, it names four positions I now hold, traces where in the course each one formed or changed and states what remains unsettled. Each position is about how a doctoral practitioner should work, not only about referrals.

Position 1: A Problem Must Be Bounded Before It Can Be Studied

I began the course with a problem stated as "referrals are falling through the cracks." By Week 3, writing the problem statement, I had to decide what the problem included: adults' outpatient specialty referrals, followed until the specialist's letter came home. More importantly, I had to decide what it excluded: clinical appropriateness, specialist capacity and payer rules. That exclusion felt uncomfortable at first, because each excluded question matters. But the boundaries are what made the problem studyable and kept the literature search from expanding without end. I now hold that defining what a problem is not is as important as defining what it is.

Where it changed: Week 3, when a classmate asked whether I was describing several problems at once, the same question I had invited in Week 1 without realizing how much it would reshape the work.

Position 2: Evidence Must Be Read for Its Setting, Not Only Its Findings

In the annotated bibliography and the literature appraisal, I found that studies of electronic referral reported benefits, while the one record-based study of completion found many referrals still unclosed even with electronic ordering (Patel et al., 2018). At first this looked like a contradiction. It dissolved once I compared outcomes and settings: the positive studies measured perceived access or communication in integrated systems where primary and specialty care share a record (Kim-Hwang et al., 2010), and none studied referrals crossing organizational boundaries. I now hold that the first question to ask of any study is whether its setting matches the setting of the decision.

Where it changed: Week 5, organizing the literature by claim rather than by source, which forced me to explain disagreements rather than list them.

Position 3: Scholarly Voice Is a Discipline of Limits

The Week 2 exercise, rewriting an opinion paragraph so every claim carried attribution and a limit, changed how I write at work. I used to write memos that moved from a problem straight to a solution, borrowing urgency from the problem to justify the fix. I now write in two steps: what we know, with sources and limits, and what we propose, with its own evidence. A review of the referral process provided the stages I used to describe the problem (Mehrotra et al., 2011), but the exercise taught me that citing a source is not the same as respecting its limits.

Where it changed: Week 2, and again in Week 10, when my critique of a classmate's draft found the same setting gap in his evidence that I had found in mine.

Position 4: Ethics Changes the Design, Not Only the Approval

Before Week 8, I thought of ethics as a review process an inquiry passes through. Writing the ethics analysis showed me that consent, identifiability and especially my dual role as director and researcher changed the inquiry's design: someone outside Tallgrass now conducts the interviews, I see only stripped transcripts, findings are used for processes rather than people and a committee checks my reading of them. Each change had a cost. The literature on the ethics of quality improvement argues that oversight should match the risks an activity imposes rather than its label (Lynn et al., 2007), and I now hold that ethical analysis belongs at the design stage, where it can change what is done.

Where it changed: Week 8, when I realized that staff might not feel free to decline an interview with their own director.

How These Positions Will Shape Next Term

The four positions translate into concrete plans. The measurement planned for next term will report completion and closure separately, by stage and by whether the specialist shares Tallgrass's record, because Positions 1 and 2 require it. My proposal to the leadership council will separate what we know from what we propose, as Position 3 requires. And the inquiry's design already includes the ethical safeguards, so that Position 4 is built in rather than added later. I also plan to keep a dated log of what I expect to find before each data pull, so that I can see later whether my expectations shaped my interpretations.

What Remains Unsettled

Three things remain unsettled. First, I still do not know the true size of the referral problem at Tallgrass; the preliminary figure rests on uncertain data, and the measurement planned for next term may change it. Second, my claim that the group itself, not each physician, must carry responsibility for closing referrals rests partly on reasoning rather than evidence from fragmented settings. If the evaluation after a year shows no improvement, I will need to revise it, and I have committed to thresholds that would tell me so. Third, I am unsure whether the dual role can ever be fully managed. The safeguards help, but I will always be the person who decides what to do with the findings, and I do not yet know whether that will bias my reading of them.

Conclusion

Four positions came out of this course: bound the problem before studying it, read evidence for its setting, write with limits and let ethics shape the design. Each formed at a specific point, often prompted by a classmate's question or my own failed first draft. What remains unsettled is the size of the problem, the strength of my proposed solution and my ability to judge my own organization fairly. Naming those uncertainties is, I think, the most doctoral thing this course taught me.

References

Kim-Hwang, J. E., Chen, A. H., Bell, D. S., Guzman, D., Yee, H. F., & Kushel, M. B. (2010). Evaluating electronic referrals for specialty care at a public hospital. Journal of General Internal Medicine, 25(10), 1123-1128. https://doi.org/10.1007/s11606-010-1402-1

Lynn, J., Baily, M. A., Bottrell, M., Jennings, B., Levine, R. J., Davidoff, F., Casarett, D., Corrigan, J., Fox, E., Wynia, M. K., Agich, G. J., O'Kane, M., Speroff, T., Schyve, P., Batalden, P., Tunis, S., Berlinger, N., Cronenwett, L., Fitzmaurice, J. M., . . . James, B. (2007). The ethics of using quality improvement methods in health care. Annals of Internal Medicine, 146(9), 666-673. https://doi.org/10.7326/0003-4819-146-9-200705010-00155

Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: Specialty referrals in the United States. The Milbank Quarterly, 89(1), 39-68. https://doi.org/10.1111/j.1468-0009.2011.00619.x

Patel, M. P., Schettini, P., O'Leary, C. P., Bosworth, H. B., Anderson, J. B., & Shah, K. P. (2018). Closing the referral loop: An analysis of primary care referrals to specialists in a large health system. Journal of General Internal Medicine, 33(5), 715-721. https://doi.org/10.1007/s11606-018-4392-z