Jennifer Gibson

Pandemic influenza preparedness: an ethical framework to guide decision-making.

BackgroundPlanning for the next pandemic influenza outbreak is underway in hospitals across the world. The global SARS experience has taught us that ethical frameworks to guide decision-making may help to reduce collateral damage and increase trust and solidarity within and between health care organisations. Good pandemic planning requires reflection on values because science alone cannot tell us how to prepare for a public health crisis.DiscussionIn this paper, we present an ethical framework for pandemic influenza planning. The ethical framework was developed with expertise from clinical, organisational and public health ethics and validated through a stakeholder engagement process. The ethical framework includes both substantive and procedural elements for ethical pandemic influenza planning. The incorporation of ethics into pandemic planning can be helped by senior hospital administrators sponsoring its use, by having stakeholders vet the framework, and by designing or identifying decision review processes. We discuss the merits and limits of an applied ethical framework for hospital decision-making, as well as the robustness of the framework.SummaryThe need for reflection on the ethical issues raised by the spectre of a pandemic influenza outbreak is great. Our efforts to address the normative aspects of pandemic planning in hospitals have generated interest from other hospitals and from the governmental sector. The framework will require re-evaluation and refinement and we hope that this paper will generate feedback on how to make it even more robust.

Setting priorities in health care organizations: criteria, processes, and parameters of success

BackgroundHospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly.DiscussionWe facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making.SummaryLessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.

Ethics and economics: does programme budgeting and marginal analysis contribute to fair priority setting?

Objective: Limited resources mean that decision-makers must set priorities among competing opportunities. Programme budgeting and marginal analysis (PBMA) is an economic approach that focuses on optimizing benefits with available resources. Accountability for reasonableness (A4R) is an ethics approach that focuses on ensuring fair priority-setting processes. PBMA and A4R have been used separately to provide decision-makers with advice about how to set priorities within limited resources. The goals of this research were to use the A4R framework to evaluate the fairness of using PBMA for priority setting and to assess how A4R might make PBMA fairer. Methods: Qualitative case studies to describe priority setting using PBMA in the Calgary Health Region (Alberta, Canada) evaluated using A4R as a conceptual framework. Results: The use of PBMA for priority setting was fairer than previous priority setting because of its emphasis on explicit rational decision-making. However, there were opportunities to improve the process, particularly by collecting data related to the decision criteria, by developing a communication plan to engage internal and external stakeholders about priority-setting, and by providing a formal mechanism to review priority-setting decisions and resolve disputes. Conclusions: There is potential for combining A4R and PBMA in a more comprehensive approach to priority setting, which uses a fair priority-setting process to reach decisions aimed at achieving optimal benefits with available resources.

Priority setting for new technologies in medicine: A transdisciplinary study

BackgroundDecision makers in health care organizations struggle with how to set priorities for new technologies in medicine. Traditional approaches to priority setting for new technologies in medicine are insufficient and there is no widely accepted model that can guide decision makers.DiscussionDaniels and Sabin have developed an ethically based account about how priority setting decisions should be made. We have developed an empirically based account of how priority setting decisions are made. In this paper, we integrate these two accounts into a transdisciplinary model of priority setting for new technologies in medicine that is both ethically and empirically based.SummaryWe have developed a transdisciplinary model of priority setting that provides guidance to decision makers that they can operationalize to help address priority setting problems in their institution.

Clinical ethicists’ perspectives on organisational ethics in healthcare organisations

Background: Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature. Objective: To describe clinical ethicists’ perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues. Design and Setting: Qualitative case study involving semi-structured interviews with 18 clinical ethicists across 13 health organisations in Toronto, Canada. Results: From the clinical ethicists’ perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation’s moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support. Conclusion: Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education.

Decision maker perceptions of resource allocation processes in Canadian health care organizations: a national survey

BackgroundResource allocation is a key challenge for healthcare decision makers. While several case studies of organizational practice exist, there have been few large-scale cross-organization comparisons.MethodsBetween January and April 2011, we conducted an on-line survey of senior decision makers within regional health authorities (and closely equivalent organizations) across all Canadian provinces and territories. We received returns from 92 individual managers, from 60 out of 89 organizations in total. The survey inquired about structures, process features, and behaviours related to organization-wide resource allocation decisions. We focus here on three main aspects: type of process, perceived fairness, and overall rating.ResultsAbout one-half of respondents indicated that their organization used a formal process for resource allocation, while the others reported that political or historical factors were predominant. Seventy percent (70%) of respondents self-reported that their resource allocation process was fair and just over one-half assessed their process as ‘good’ or ‘very good’. This paper explores these findings in greater detail and assesses them in context of the larger literature.ConclusionData from this large-scale cross-jurisdictional survey helps to illustrate common challenges and areas of positive performance among Canada’s health system leadership teams.

Organizational ethics and the management of health care organizations

What is organizational ethics? Organizational ethics is an emerging area in health care management. Health care organizations have tended to focus on the ethical issues faced by clinicians in the direct delivery of clinical care (i.e., clinical ethics) or by researchers in the conduct of clinical research (i.e., research ethics). Organizational ethics is concerned with the ethical issues faced by managers and board members and the ethical implications of organizational decisions and practices on patients, staff, and the community. Recent emphasis on ethics in health services accreditation and health care leader certification is contributing to a search for leading practices in organizational ethics. However, there remain significant gaps in knowledge about what ethical issues health care leaders are facing or how organizational ethics can be approached in practice.

Using evaluation theory in priority setting and resource allocation

PURPOSE Public sector interest in methods for priority setting and program or policy evaluation has grown considerably over the last several decades, given increased expectations for accountable and efficient use of resources and emphasis on evidence-based decision making as a component of good management practice. While there has been some occasional effort to conduct evaluation of priority setting projects, the literatures around priority setting and evaluation have largely evolved separately. In this paper, the aim is to bring them together. DESIGN/METHODOLOGY/APPROACH The contention is that evaluation theory is a means by which evaluators reflect upon what it is they are doing when they do evaluation work. Theories help to organize thinking, sort out relevant from irrelevant information, provide transparent grounds for particular implementation choices, and can help resolve problematic issues which may arise in the conduct of an evaluation project. FINDINGS A detailed review of three major branches of evaluation theory--methods, utilization, and valuing--identifies how such theories can guide the development of efforts to evaluate priority setting and resource allocation initiatives. Evaluation theories differ in terms of their guiding question, anticipated setting or context, evaluation foci, perspective from which benefits are calculated, and typical methods endorsed. ORIGINALITY/VALUE Choosing a particular theoretical approach will structure the way in which any priority setting process is evaluated. The paper suggests that explicitly considering evaluation theory makes key aspects of the evaluation process more visible to all stakeholders, and can assist in the design of effective evaluation of priority setting processes; this should iteratively serve to improve the understanding of priority setting practices themselves.

Organizational ethics: no longer the elephant in the room.

Organizational ethics is concerned with the ethical issues encountered in the management and governance of health organizations; the ethical implications of organizational decision making on key stakeholders (eg, patients, staff, and the community); and the ethical complexities of balancing the goal of quality patient care with other important goals such as financial sustainability, staff well-being, learning and innovation, and public accountability. Mission and value statements are sometimes described as the organization’s “moral compass” for it is through its mission and value statements that an organization articulates the core standards according to which its decisions and actions are to be judged. However, ethical issues arise when missionbased commitments or espoused values are in tension or conflict. Thus, the goals of organizational ethics are not only to achieve a strong alignment between the organization’s stated mission and values and the decisions and actions taken by individuals on behalf of the organization but also to create an organizational climate in which organizational ethics issues can be constructively addressed. In other words, organizational ethics calls on health institutions “to define their core values and mission, identify areas in which important values come into conflict, seek the best possible resolution of these conflicts, and manage their own performance to ensure that it acts in accord with espoused values.” Over the last 10 years, there has been a dramatic increase in attention paid to ethics in Canadian health institutions. The Canadian College of Health Leaders has defined a Code of Ethics and identified ethics explicitly among the professional competencies of health leaders, most notably in its LEADS in a Caring Environment leadership capability framework. Accreditation Canada and its US counterpart, the Joint Commission on Accreditation

An evaluation tool for assessing performance in priority setting and resource allocation: multi-site application to identify strengths and weaknesses:

Introduction An evaluation tool should help improve formal priority setting and resource allocation (PSRA) processes in Canada and elsewhere. These are crucial to maximizing value from limited resources. Methods On the basis of case studies, balanced scorecard development protocols and use-focused evaluation principles, an evaluation tool was developed based on an existing framework for high PSRA performance and implemented in two health care organizations in British Columbia, Canada. Results Implementation of the tool identified areas of strength, improvement and weakness in the pilot organizations’ processes for PSRA including: communication, staff engagement and culture. Refinements were identified and incorporated into the tool for future application. Conclusion This is the first documented multi-site application of such an evaluation tool. Broader dissemination should have use both in further refining the basis of the tool and in catalysing improved performance of PSRA practice.