DDHA 8006 Week 8 Practice Inquiry Ethics Analysis Example

Consent, Identifiability and Two Hats: An Ethics Analysis of a Referral Completion Inquiry Led by the Organization's Own Director

Student Name

Walden University

DDHA 8006: Doctor of Healthcare Administration Foundational Concepts

Instructor Name

Month Day, Year

Consent, Identifiability and Two Hats: An Ethics Analysis of a Referral Completion Inquiry Led by the Organization's Own Director

The Inquiry Under Review

The practice inquiry developed in this course would study unclosed specialty referrals at Tallgrass Medical Group, a composite nine-practice primary care group. As designed, it would pull 300 referrals at random from twelve months of orders, trace each through scheduling, attendance and report return, stages drawn from a review of where referrals break down (Mehrotra et al., 2011), using the record, call specialist offices to confirm visits and call a subset of patients to ask why they did not attend. It would also interview eight to ten clinicians and staff about how referrals are handled. The person leading the inquiry is the group's director of operations, who is also a doctoral student. This analysis examines three ethical pressures on that design, consent, identifiability and dual role, and states what each pressure does to the work.

Is It Research or Quality Improvement?

The first question is which rules apply. Activities intended to improve care within an organization have traditionally been treated as quality improvement and handled through local oversight, whereas work meant to produce knowledge that travels beyond the organization has usually gone to an institutional review board as research. That distinction has been criticized as unstable, because many activities do both, and some scholars argue that ethical oversight should depend on the risks and burdens an activity imposes rather than on its label (Kass et al., 2013). An influential analysis of the ethics of quality improvement made a similar point: quality improvement can carry real risks to patients and staff, and should receive ethical review proportionate to those risks (Lynn et al., 2007).

This inquiry will be submitted to the university's review board because it is part of a doctoral program and its findings will be written up. But the analysis below would apply even if it were run purely as internal improvement, because the ethical pressures arise from what the inquiry does, not from what it is called.

Pressure 1: Consent

Tracing referrals through the record does not require contact with patients, and reviewing records for operations is a routine use of health information. Calling patients is different. A call from the organization asking why a patient missed a specialist appointment may feel intrusive, may be heard as blame and may reach a patient who did not attend for reasons they prefer to keep private, such as cost or fear of a diagnosis.

What this pressure does to the work: patient calls will open with a short script explaining the purpose, making clear the patient may say no and that saying no changes nothing about their care, and offering to arrange the missed appointment if the patient wishes. Calls will be made by a nurse rather than the director, so that patients hear from someone in a care role. Patients who decline will be recorded only as having declined. Staff interviews will use written consent, which is easier to give freely, though as discussed below, freedom is limited by the dual role.

Pressure 2: Identifiability

The sample will contain patients' names, diagnoses implied by specialty and in some cases sensitive specialties such as behavioral health or infectious disease. Staff interviews will reveal how particular practices handle referrals, which could identify individual employees, especially in small practices.

What this pressure does to the work: the dataset will be coded, with the key held separately, and behavioral health and infectious disease referrals will be excluded from the patient call subset to reduce the risk of disclosure. In reporting, practice-level findings will be combined so that no practice with fewer than four clinicians is reported alone. Quotations from staff will be checked to remove details that could identify the speaker. The cost of these protections is some loss of detail, for example the inability to compare the smallest practices, which the report will state as a limit.

Pressure 3: Two Hats

The most important pressure is the dual role. The person leading the inquiry is the director of operations, to whom many of the interviewees report directly or indirectly. Staff asked by their director how they handle referrals may not feel free to decline, and may describe what they think the director wants to hear rather than what they do. Findings that reflect poorly on a practice could, in principle, affect how that practice is managed. Patients, too, may feel differently about a call that they learn is part of a study by the organization's management.

What this pressure does to the work: staff interviews will be conducted by a doctoral colleague from outside the organization, using the same guide, and recordings will be transcribed and de-identified before the director sees them. Interviewees will be told in writing that participation will not affect evaluations and that the director will not know who declined. The director will not use any finding about an individual employee for personnel decisions; findings will be used only at the process level. Where the director is also the decision maker on changes, the analysis will be reviewed by the quality committee before changes are made, so that the director's interpretation is checked by others.

Table 1

Pressures and What They Do to the Work

Each pressure changes the design, and each change has a cost the report will acknowledge.

Conclusion

The referral inquiry raises three ethical pressures. Consent shapes how patients are contacted, identifiability shapes how data are held and reported and the dual role, the director studying the director's own organization, shapes who conducts interviews and how findings may be used. Each pressure changes the work and costs something. Naming those costs is part of conducting the inquiry ethically, because it tells readers what the findings can and cannot show.

References

Kass, N. E., Faden, R. R., Goodman, S. N., Pronovost, P., Tunis, S., & Beauchamp, T. L. (2013). The research-treatment distinction: A problematic approach for determining which activities should have ethical oversight. Hastings Center Report, 43(s1), S4-S15. https://doi.org/10.1002/hast.133

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