MHA 542 Week 3 Modeling Ethical Decision Making Example

Thirty Hours in a Hallway: Modeling Ethical Decision Making When Emergency Boarding Collides With Elective Surgery Revenue

[Student Name]

University of Phoenix

MHA/542: Leading with Authenticity in the Health Sector

Week 3 Assignment

[Instructor Name]

[Date]

The medical center, its boarding figures, finances and decision are composites written for a model paper; research findings come from the sources cited.

On a Tuesday morning in January, the emergency department of a western Michigan medical center held 22 admitted patients in hallways and treatment rooms, waiting for inpatient beds. The longest had waited 30 hours. At the same time, the operating rooms were running a full elective schedule, and patients recovering from planned surgery filled beds that emergency patients needed. The emergency physicians asked the chief operating officer to cut elective surgery. The surgeons asked her to protect it. This paper shows how she made the decision and how she made her reasoning visible.

A Genuine Dilemma

Both requests were legitimate. Boarded emergency patients were receiving care in hallways, with nurses stretched and monitoring harder. Elective surgery patients had waited weeks for procedures that would relieve pain or treat disease. Elective cases also generated a large share of the medical center's margin, which funded services and jobs. No option protected everyone.

What Boarding Does to Patients

Evidence shows that boarding carries risk. Researchers following every admission from one busy emergency department over a period of years, more than 41,000 in all, saw in-hospital deaths climb steadily with time spent waiting: 2.5% for patients moved upstairs within 2 hours, 4.5% for those left waiting half a day or longer. Hospital stays grew longer too, and adjusting for how sick patients were did not erase either pattern (Singer et al., 2011). The study shows association rather than proof of cause, but it points toward real harm.

What Boarding Does to Staff

Staff pay a price too. An institution-wide survey of clinicians found that watching patient care suffer because of poor continuity and communication was the highest-ranked source of moral distress across professions, and that clinicians who left or considered leaving a position had significantly higher moral distress (Whitehead et al., 2015). Emergency nurses had told the chief nursing officer that caring for patients in hallways for a day or more was the reason several were considering leaving. Boarding harms the patients in the hallway and wears down the people caring for them.

What Cutting Surgery Would Do

Reducing elective inpatient surgery would delay care for patients with painful conditions, frustrate surgeons and cost an estimated $1.1 million in contribution margin per month. It would not delay urgent or cancer operations.

Choosing a Framework

The chief operating officer turned to a framework built for rationing choices on which thoughtful people differ. It requires four conditions: publicity, meaning the decision and its rationale are publicly available; relevance, meaning the reasons given are ones that impartial observers would accept as bearing on the choice; revision and appeals, meaning there is a way to challenge and revise the decision as new evidence arrives; and enforcement, meaning the process ensures the other conditions are met (Daniels & Sabin, 1997).

Relevance: Gathering the Reasons

She convened the chiefs of surgery and emergency medicine, the nursing and finance executives, a bed management leader, an ethics committee member and a patient advisor. Each presented the considerations they believed relevant. The group agreed that patient safety evidence, clinical urgency, staff capacity and financial sustainability were all relevant; convenience and surgeon preference alone were not.

Considering Options

The group considered four options: no change; cancel all elective inpatient surgery; reduce elective inpatient cases by a set share while protecting urgent and cancer cases and outpatient surgery; and add temporary beds by opening a closed unit with agency staff. Opening the closed unit was pursued in parallel but would take three weeks.

The Decision

The chief operating officer chose to reduce elective inpatient surgery by 30% for four weeks, protecting cancer, urgent and outpatient procedures, with surgeons choosing which cases to postpone based on clinical need. Emergency boarding over 12 hours would be reviewed daily.

Publicity: Showing the Reasoning

She wrote a one-page rationale and shared it with all physicians and staff and with the patient and family advisory council. It stated the problem, the evidence on boarding, the options considered, the decision, what it would cost and when it would be reviewed. She also presented it at medical staff meetings and answered questions.

Revision and Appeals

The decision included a review after two weeks and a process for surgeons to request exceptions for individual patients, decided by the chief medical officer within 24 hours. Five exceptions were requested and four granted.

Enforcement

The bed management team tracked elective volumes and boarding daily and reported them to the group, so everyone could see whether the decision was being carried out as stated.

Listening to Surgical Patients

The patient advisor on the group raised a perspective no one else had: patients waiting for hip and knee replacements were often in severe pain, sleeping poorly and unable to work, and a four-week delay was not trivial to them. Her comments led to two changes: surgeons would call each postponed patient personally, and postponed patients would receive the first available dates when the schedule reopened.

Her Own Discomfort

The chief operating officer found the decision hard. She had led surgical services for years and knew many of the surgeons as colleagues and friends. She said so openly at the medical staff meeting, explaining that she felt the weight of delaying their patients' care but could not accept patients waiting a day or more in hallways. Naming her own discomfort made the decision feel less like an order from above and more like a shared burden.

The Surgeons' Response

Most surgeons accepted the decision once they saw the rationale and the exception process. Two objected strongly and asked for an appeal to the medical executive committee, which reviewed the rationale and upheld the decision. The appeal itself showed that the process allowed challenge, which strengthened its legitimacy.

What Others Learned

Modeling ethical decision making means others can see how a leader reasons, not only what she decides. Directors later used the same one-page rationale format for their own difficult decisions, including a staffing reduction in outpatient clinics.

Results

Over four weeks, the number of patients boarding more than 12 hours fell by about two thirds, emergency nurse overtime fell and no urgent surgery was delayed. The closed unit reopened in week three, and elective surgery returned to full volume in week five, with postponed patients scheduled first.

Honest Costs

The decision cost roughly $1.1 million in margin and delayed care for about 90 patients. The chief operating officer acknowledged these costs openly rather than presenting the decision as costless.

Conclusion

Emergency boarding and elective surgery presented a genuine conflict between legitimate goods. Evidence on boarding mortality and moral distress clarified the stakes, and a fairness framework requiring publicity, relevant reasons, revision and enforcement guided a decision others could understand and challenge. By making her reasoning visible, the chief operating officer modeled how ethical decisions should be made across the medical center.

References

Daniels, N., & Sabin, J. (1997). Limits to health care: Fair procedures, democratic deliberation, and the legitimacy problem for insurers. Philosophy & Public Affairs, 26(4), 303-350. https://doi.org/10.1111/j.1088-4963.1997.tb00082.x

Singer, A. J., Thode, H. C., Jr., Viccellio, P., & Pines, J. M. (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324-1329. https://doi.org/10.1111/j.1553-2712.2011.01236.x

Whitehead, P. B., Herbertson, R. K., Hamric, A. B., Epstein, E. G., & Fisher, J. M. (2015). Moral distress among healthcare professionals: Report of an institution-wide survey. Journal of Nursing Scholarship, 47(2), 117-125. https://doi.org/10.1111/jnu.12115