In his public presentations, Dr Douglas Martin, PhD, a
priority-setting expert and University of Toronto assistant
professor, likes to tell the history of Canadian healthcare
by focusing on the jargon and euphemism that seems to
follow the age-old question "where should the money go?"
"Over the last 10 or 15 years,
the language surrounding this issue has gone through
a gradual sanitization," he told one audience in Montreal.
"What was first called 'rationing' became 'resource
allocation' and, after that, 'priority-setting'... it's
now called 'sustainability'."
Whatever the vogue word of the
day is, priority-setting — distributing goods and
services among programs and people — remains a
top goal for Canadian health institutions. And it's
not just a case of caregivers and administrators being
able to boast that they run a tight ship — this
stuff is central to the kind of care patients receive.
It determines what new drugs or treatments will be used,
where to allocate staff, and what procedures or programs
are ready for some heavy liposuction or even outright
removal.
CAREFUL
WITH THAT AXE
Until recently, many hospitals simply opted for across-the-
board cuts or left it to an executive committee to determine
priority setting. But according to a recent survey of
86 hospital CEOs in Ontario, things are changing.
Professor Martin, who works in
the department of Health Administration and Public Health
Sciences and the Joint Center of Bioethics at the University
of Toronto, co-authored the survey: What do hospital
decision-makers in Ontario, Canada, have to say about
the fairness of priority-setting in their institutions?
One of the key questions asked
respondents to rate the fairness of their priority-setting
program. Overall, 60.7% of respondents indicated their
hospital's priority-setting was fair. He says there
are three key conclusions to draw from the data.
"First, hospitals in Ontario in
general do a pretty good job of meeting the conditions
of fairness in priority-setting," he says. "Second,
there is room for improvement; and third, 'accountability
for reasonableness' provides the kind of guidance that
CEOs need to improve in their institutions."
THE
HARVARD PROCESS
"Accountability for reasonableness" is the dominant
process for ensuring fair priority-setting. It is based
on criteria set out by two Harvard medical ethicists,
Dr Norman Daniels, PhD, and Dr James Sabin, MD, to help
assess whether a priority-setting procedure is reasonable
and, ultimately, fair.
"It holds that we must develop
processes to make decisions that seem to be fair in
the context of our democratic institutions and democratically-oriented
society," says Professor Martin.
"Accountability for reasonableness"
has four conditions: there must be publicity to assure
transparency of the decision and the grounds for reaching
it; decisions must be relevant to overall goals and
personal needs; there must be opportunities for appeal
of decisions and for revisions over time; and there
must be strict enforcement to assure that the other
conditions are met.
On this scale, survey respondents
said their hospitals performed best for the relevance
condition (75.0%), followed by appeals/revision (56.6%),
publicity (56.0%), and with enforcement (39.5%) lagging
behind.
FAIRNESS
IN ACTION
Dr Jack Kitts, president and CEO of The Ottawa Hospital,
recently completed a priority-setting exercise at his
institution, and found "accountability for reasonableness"
to be helpful in ensuring the results were fair.
"The good thing about it is that
at the end of the [priority-setting] exercise, because
of the approach and process, the department heads couldn't
argue that the process to come to the decisions wasn't
fair," he says, "It enables you to make really difficult
decisions without causing a lot of controversy."
Dr Kitts and his staff worked with
department heads every step of the way and asked them
to produce 'work books' that showed how their programs
contributed to the overall goals of the institution.
Hospital executives, including the vice president of
medical affairs, then ranked the books on their contribution
to the hospital's goals and made rationing decisions
accordingly. Medical staff were then given the opportunity
to appeal any decision.
"Now we know exactly what we have
to focus on to meet our objectives," Dr Kitts says,
"and we know which areas we can divest."
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