exercise with examples - National Center for Ethics in Health Care

10. _____How to handle a complaint that a staffmember from the billing office was observed using theoffice copy machine to copy flyers for a neighborhoodbarbeque. This complaint was reported by a colleagueof the employee to the billing office team leader.15. _____What to do upon learning that the DentalService Chief who is overseeing the developmentof fee services is also providing consultation toa practice that may bid on those services.11. _____What to do about a nurse who refuses totreat a patient in the ICU for reasons of “conscience.”The nurse has talked to her supervisor and thedirector of the ICU. The facility has a policy that givesthe supervisor discretion to determine whetherthe refusal is appropriate, but the supervisoris still not sure what the right thing to do is.16. _____How to respond to a report that Veterans’pre-payments are being posted to the generalfund instead of being returned to Veterans. Arevenue cycle manager noted that at least threeveterans had asked about missing refunds andwhether they could be applied to future care.12. _____What to do about an employee whois allegedly selling VA hospital equipment that isno longer in use, to non-VA organizations. Theequipment being sold is in working condition,but due to recent upgrades at the facility, it hasall been moved to a storage room until it can bedecommissioned. This allegation has been reportedto the Associate Director who is unsure what to do.17. _____How to respond to survey findingsthat 40% of nursing home staff perceives thatcomputers in nursing stations are “almost always”left unattended with personal health informationvisible on the screen. The ISO and Privacy Officerare aware that this is a problem but their attemptsat resolution have not been successful.13. _____Which patients will get a pharmaceuticalproduct that is in short supply. None of the patientsrequiring the product are considered more ill thanothers. The pharmacy is not sure when more of theproduct will arrive, or even if they will receive more.18. _____What to do if nursing students areusing a non-VA approved web-based softwarepackage to share patient information in order tofacilitate their learning and ensure quality handoffsfrom student to student. The software packagerequires a login and students have offered to allowpreceptors to monitor the posted information.14. _____What to do if the quality manager forsurgical services reports that adverse events thatshould have been disclosed to patients or surrogatedecision makers were not disclosed consistently.The facility has a policy in place but despitetraining, clinical staff still seem confused about thedisclosure policy and how best to implement it.3 Triage Tool for Ethics-Related Leadership Decisions

Decision Exercise: Triage Tool for Ethics-Related Leadership Decisions Answer SheetExercise Goal:To practice using the Triage Tool forEthics-Related Leadership DecisionsTime:10 -15 minutesAcƟvity Format:• Work in groups or complete individually• Read examples• Use Triage Tool for Ethics-Related Leadership Decisions • Determine the type of decision thatmust be made and the individual,mechanism, or service best suited toassist with the ethics-related decision• Check answers and discussMaterials Needed:• Triage Tool for Ethics-Related Leadership Decisions • Pen/pencil• Answer keyNote:Use this exercise during a leadership meetingin conjunction with the Triage ToolDirecƟons:As a group, read and discuss each of theexamples below and do the following:1. Determine what type of decision must be madein each example and fill in the correspondingletter below. Types include:A. Decision relates to an ethical concernB. Decision relates to a systemslevelethics quality gapC. Decision relates to Government EthicsD. Decision relates to an ethics violation2. For all A responses use the Triage Toolfor Ethics-Related Leadership Decisions,including the Ethical Leadership Quality Checkembedded within the tool, to determine anappropriately systematic decision makingprocess, then determine the individual,mechanism, or service best suited toassist with the ethics-related decision.3. For all B, C, and D responses use the Triage Tool for Ethics-Related Leadership Decisions to determine the individual, mechanism, or service best suited to assist with the ethics-related decision. 4. Check answers using the answer key and discuss.Disclaimer – Each of the examples below has todo with ethics in different ways. This exercise andthe answers are intended for practice only anddo not constitute a legal decision or legal advice.Please seek assistance from the appropriate officeand/or the Ethics Consultation Service if you havequestions concerning an ethics-related decision.

Scenarios with Answers A1. _____What to do if Regional Counsel has said anemployee can legally do something, but the employeestill feels uneasy about it and is unsure how to proceed.A, This decision pertains to uncertainty orconflict about values when the “right thing todo” is unclear. After determining the decisionrequires additional ethical analysis, it would beappropriate to request an ethics consultation.C 2. _____Whether to accept an offer from a patientto purchase and install blinds for the telemetryunit. The blinds are relatively cheap, yet wouldyield significant impact on patient privacy. Thepatient who has offered to purchase and installthe blinds does not use telemetry services.C, This decision relates to a legal question aboutstandards of ethical conduct for employees ofthe executive branch – in this case, the rules onaccepting gifts. Legal advice on Government Ethicsrules must be obtained from the Designated AgencyEthics Official (DAEO) or Regional Counsel. If aDeputy Ethics Official determines that accepting thegift would be legally permissible, there might still beuncertainty or conflict about whether accepting agift is the “right thing to do,” in which case it wouldbe appropriate to request an ethics consultation.D3. _____What to do about a researcher who isaccused of falsifying clinical data for a study. Thisresearcher has had the same position for manyyears and is nearing retirement. There have beenno previous accusations against the researcher.D, Specific allegations related to fabrication,falsification, or plagiarism (“Research Misconduct”)should be referred to the Research IntegrityOfficer (RIO) at the VA Medical Center conductingthe research and/or the Office of ResearchOversight (ORO) in VA Central Office.B.4. _____How to handle complaints receivedby the ICU nurse manager from families thathad been approached for possible organdonation after the patients had expresseda preference against organ donation.B, This decision relates to a disparity betweenbest ethics practice (ideal establishedon the basis of ethical standards, norms,or expectations for the conduct of anorganization and its staff) and currentethics practice resulting from system orprocess failures. It would be appropriateto refer this issue to the IE PE Team orother quality improvement mechanism.D 5. _____What to do about a complaint of“favoritism” in the hiring of a new leader. Thecomplaint was made by a member of the hiringpanel. The new leader has not started yet but isexpected to begin work within the next week.D, This decision relates to allegations ofadministrative misconduct—specifically there isan allegation of prohibited personnel practices.As a general rule, this type of allegation isbest handled within the supervisory chainof command (for example, by the FacilityDirector). Sometimes a leader may convenean administrative investigation board todetermine the facts of the case. If for somereason the problem cannot be effectivelyhandled within the facility (e.g., becausethe individual reporting the allegation fearsrepercussions), it would be appropriate tocontact the U.S. Office of Special Counsel.Triage Tool for Ethics-Related Leadership Decisions 2Answer Sheet

C 6. _____How to respond to an employee who ismarketing a book that closely relates to his/her VA job.The book has been published by a major publisher andis available for purchase online. The employee is onlymarketing the book during lunch time and on breaks. Acolleague of the employee reported it to the employee’ssupervisor, who needs to decide what to do.C, This decision relates to a legal question aboutstandards of ethical conduct for employees of theexecutive branch – in this case potential misuse ofofficial position, time, and resources. Legal adviceon Government Ethics rules must be obtainedfrom the Designated Agency Ethics Official(DAEO) or Regional Counsel or Professional StaffGroup III (PSG) at governmentethics@va.gov.A 7. _____What to do in a situation where the patient hasdecision making capacity and wants to return home, butthe family and clinical staff are making arrangements fornursing home placement because they do not believethe patient will be safe at home. The clinical staff hasasked the Chief Medical Officer what they should do.A, This decision pertains to uncertainty or conflictabout values when the “right thing to do” isunclear. After determining that the decisionrequires additional ethical analysis, it would beappropriate to request an ethics consultation.B8. _____What to do if recent chart review findings revealonly 10% of requests for assistance with completing advancedirectives are followed up on by clinic staff. Ideally thisnumber should be 100%. It is unclear from the audit howlong this has been going on. The situation has been broughtto the attention of the nurse manager of the clinic.9. _____How D to handle a situation where asurgeon is accused of being verbally abusivetoward staff. This particular surgeon hashad numerous complaints from various staffmembers; however there have been nocomplaints from patients or family members.D, This decision relates to a report orevidence of a violation of an ethicalstandard – specifically, there is an allegationof unprofessional behavior, which is atype of administrative misconduct. As ageneral rule, this type of allegation is besthandled within the supervisory chain ofcommand (for example, by the Chief ofStaff). If you are the leader responsible (orthe supervisor with leadership authority)over the service/area for which thisquestion is arising, it is your responsibilityto investigate the situation and identify anappropriate course of action. Sometimesa leader may convene an administrativeinvestigation board to determine thefacts of the case. In contrast, allegationsof serious waste, fraud, or abuse as wellas allegations of criminal activity shouldbe referred to the Inspector General orlaw enforcement authorities. Concernsabout unprofessional behavior mayalso be referred to an appropriate statelicensing board. If you need informationabout professional ethics standards youcan request assistance from the ethicsconsultation service.B, Decisions that relate to a disparity betweenbest ethics practice (ideal established on the basisof ethical standards, norms, or expectations forthe conduct of an organization and its staff) andcurrent ethics practice resulting from system orprocess failures should be referred to the IE PETeam or other quality improvement mechanism.3Triage Tool for Ethics-Related Leadership DecisionsAnswer Sheet

C10. _____How to handle a complaint thata staff member from the billing office wasobserved using the office copy machine tocopy flyers for a neighborhood barbeque. Thiscomplaint was reported by a colleague of theemployee to the billing office team leader.C, VA has specific policies pertaining to theuse of government equipment for personaluse. Legal questions about standards ofethical conduct for employees of the executivebranch—in this case a question aboutpotential misuse of official position, time,and/or resources – should be referred to aDesignated Agency Ethics Official (DAEO) orRegional Counsel or Professional Staff GroupIII (PSG) at governmentethics@va.gov.A 11. _____What to do about a nurse whorefuses to treat a patient in the ICU for reasonsof “conscience.” The nurse has talked to hersupervisor and the director of the ICU. Thefacility has a policy that gives the supervisordiscretion to determine whether the refusalis appropriate, but the supervisor is stillnot sure what the right thing to do is.A, This decision relates to uncertainty orconflict about values when the “right thingto do” is unclear. Because the supervisor isunsure how to apply the policy within herallowed discretion, it would be appropriateto request an ethics consultation to discussthe range of ethically justifiable options.D 12. _____What to do about an employee whois allegedly selling VA hospital equipment that isno longer in use, to non-VA organizations. Theequipment being sold is in working condition,but due to recent upgrades at the facility, it hasall been moved to a storage room until it can bedecommissioned. This allegation has been reportedto the Associate Director who is unsure what to do.D, Allegations or evidence of criminal conduct,such as selling hospital equipment illegally, shouldbe referred to management officials, VA Police,and the VA Office of the Inspector General. Ifyou have questions about whether the allegedbehavior is illegal, seek assistance from RegionalCounsel or the Office of General Counsel.A 13. _____Which patients will get a pharmaceuticalproduct that is in short supply. None of the patientsrequiring the product are considered more ill thanothers. The pharmacy is not sure when more of theproduct will arrive, or even if they will receive more.A, This decision pertains to uncertainty orconflict about values when the “right thing todo” is unclear. After determining the decisionrequires additional ethical analysis, it would beappropriate to request an ethics consultation.B 14. _____What to do if the quality manager forsurgical services reports that adverse events thatshould have been disclosed to patients or surrogatedecision makers were not disclosed consistently.The facility has a policy in place but despitetraining, clinical staff still seem confused about thedisclosure policy and how best to implement it.B, Decisions that relate to a disparity betweenbest ethics practice (ideal established on the basisof ethical standards, norms, or expectations forthe conduct of an organization and its staff) andcurrent ethics practice resulting from system orprocess failures should be referred to the IE PETeam or other quality improvement mechanism.Triage Tool for Ethics-Related Leadership DecisionsAnswer Sheet4

C 15. _____What to do upon learning that the DentalService Chief who is overseeing the developmentof fee services is also providing consultation toa practice that may bid on those services.C, Legal questions about standards of ethicalconduct for employees of the executive branch– in this case conflicts of interest that wouldhave a direct and predictable effect on theemployee’s own financial interests – should bereferred to a Designated Agency Ethics Official(DAEO) or Regional Counsel or ProfessionalStaff Group III (PSG) at governmentethics@va.gov. It may also be appropriate to contactthe facility’s Compliance and Business IntegrityOfficer or the National CBI Helpline.D16. _____How to respond to a report that Veterans’pre-payments are being posted to the generalfund instead of being returned to Veterans. Arevenue cycle manager noted that at least threeveterans had asked about missing refunds andwhether they could be applied to future care.D, Allegations of noncompliance with legalor regulatory standards related to revenueprogram oversight should be referred tothe facility’s Compliance and BusinessIntegrity Officer or the National Complianceand Business Integrity Helpline.B 17. _____How to respond to survey findingsthat 40% of nursing home staff perceives thatcomputers in nursing stations are “almost always”left unattended with personal health informationvisible on the screen. The ISO and Privacy Officerare aware that this is a problem but their attemptsat resolution have not been successful.B, Decisions that relate to a disparity betweencurrent practices and ideal practices from anethical perspective should be referred to the IE PETeam or other quality improvement mechanism.18. _____What D to do if nursing students areusing a non-VA approved web-based softwarepackage to share patient information in order tofacilitate their learning and ensure quality handoffsfrom student to student. The software packagerequires a login and students have offered to allowpreceptors to monitor the posted information.D, Allegations of non-compliance with VA Privacyrules should be referred to both the PrivacyOfficer as well as the Information Security Officer(ISO). If the students are conducting research, theproblem involves regulatory noncompliance andshould be referred to the facility’s InstitutionalReview Board (IRB) or directly to the Office ofResearch Oversight (ORO) in VA Central Office.5 Triage Tool for Ethics-Related Leadership DecisionsAnswer Sheet