SARS and hospital priority setting: a qualitative case study and evaluation

Jennifer Ah Bell,Sylvia Hyland,Ross Eg Upshur,Tania Depellegrin,Douglas K Martin,Mark Bernstein

doi:10.1186/1472-6963-4-36

Abstract

BackgroundPriority setting is one of the most difficult issues facing hospitals because of funding restrictions and changing patient need. A deadly communicable disease outbreak, such as the Severe Acute Respiratory Syndrome (SARS) in Toronto in 2003, amplifies the difficulties of hospital priority setting. The purpose of this study is to describe and evaluate priority setting in a hospital in response to SARS using the ethical framework 'accountability for reasonableness'.MethodsThis study was conducted at a large tertiary hospital in Toronto, Canada. There were two data sources: 1) over 200 key documents (e.g. emails, bulletins), and 2) 35 interviews with key informants. Analysis used a modified thematic technique in three phases: open coding, axial coding, and evaluation.ResultsParticipants described the types of priority setting decisions, the decision making process and the reasoning used. Although the hospital leadership made an effort to meet the conditions of 'accountability for reasonableness', they acknowledged that the decision making was not ideal. We described good practices and opportunities for improvement.Conclusions'Accountability for reasonableness' is a framework that can be used to guide fair priority setting in health care organizations, such as hospitals. In the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less.

Highlights

Priority setting is one of the most difficult issues facing hospitals because of funding restrictions and changing patient need
This study examined priority setting at one Toronto hospital as it responded to the 2003 Severe Acute Respiratory Syndrome (SARS) crisis
We identified the following good practices: 1) staff and patient safety was the primary criterion in decision making, but each decision was based on a cluster of relevant reasons – decision makers' use of clusters of relevant reasons has been identified and discussed in a previous study [16], 2) decisions were regularly accessible on hospital email, intranet and the world-wide web; 3) challenges were addressed directly by the CEO; 4) hospital leadership made a concerted effort to meet the conditions of 'accountability for reasonableness'

Summary

Introduction

Priority setting is one of the most difficult issues facing hospitals because of funding restrictions and changing patient need. A deadly communicable disease outbreak, such as the Severe Acute Respiratory Syndrome (SARS) in Toronto in 2003, amplifies the difficulties of hospital priority setting. In Toronto there were forty-four SARS related deaths and over 100 health care workers contracted SARS, placing intense pressure on Toronto's public health and hospital system [1] Due to both the importance of hospitals in any health system and the difficulties they face, improving priority (page number not for citation purposes). Rationales for priority setting decisions must rest on reasons (evidence and principles) that 'fair-minded' people can agree are relevant in the context. 'Fair-minded people seek to cooperate according to terms they can justify to each other – this narrows, though does not eliminate, the scope of controversy, which is further narrowed by specifying that reasons must be relevant to the specific priority setting context.

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