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Douglas K Martin

Publications and source records attributed to Douglas K Martin.

At least 19 recordsLinked to original sources
PubMed2006

Priority setting at the micro-, meso- and macro-levels in Canada, Norway and Uganda.

UNLABELLED: The objectives of this study were (1) to describe the process of healthcare priority setting in Ontario-Canada, Norway and Uganda at the three levels of decision-making; (2) to evaluate the description using the framework for fair priority setting, accountability for reasonableness; so as to identify lessons of good practices. METHODS: We carried out case studies involving key informant interviews, with 184 health practitioners and health planners from the macro-level, meso-level and micro-level from Canada-Ontario, Norway and Uganda (selected by virtue of their varying experiences in priority setting). Interviews were audio-recorded, transcribed and analyzed using a modified thematic approach. The descriptions were evaluated against the four conditions of "accountability for reasonableness", relevance, publicity, revisions and enforcement. Areas of adherence to these conditions were identified as lessons of good practices; areas of non-adherence were identified as opportunities for improvement. RESULTS: (i) DESCRIPTION: at the macro-level, in all three countries, cabinet makes most of the macro-level resource allocation decisions and they are influenced by politics, public pressure, and advocacy. Decisions within the ministries of health are based on objective formulae and evidence. International priorities influenced decisions in Uganda. Some priority-setting reasons are publicized through circulars, printed documents and the Internet in Canada and Norway. At the meso-level, hospital priority-setting decisions were made by the hospital managers and were based on national priorities, guidelines, and evidence. Hospital departments that handle emergencies, such as surgery, were prioritized. Some of the reasons are available on the hospital intranet or presented at meetings. Micro-level practitioners considered medical and social worth criteria. These reasons are not publicized. Many practitioners lacked knowledge of the macro- and meso-level priority-setting processes. (ii) Evaluation-relevance: medical evidence and economic criteria were thought to be relevant, but lobbying was thought to be irrelevant. Publicity: all cases lacked clear and effective mechanisms for publicity. REVISIONS: formal mechanisms, following the planning hierarchy, were considered less effective, informal political mechanisms were considered more effective. Canada and Norway had patients' relations officers to deal with patients' dissensions; however, revisions were more difficult in Uganda. Enforcement: leadership for ensuring decision-making fairness was not apparent. CONCLUSIONS: The different levels of priority setting in the three countries fulfilled varying conditions of accountability for reasonableness, none satisfied all the four conditions. To improve, decision makers at the three levels in all three cases should engage frontline practitioners, develop more effectively publicized reasons, and develop formal mechanisms for challenging and revising decisions.

Health Personnel↗
PubMed2006

Priority setting in developing countries health care institutions: the case of a Ugandan hospital.

BACKGROUND: Because the demand for health services outstrips the available resources, priority setting is one of the most difficult issues faced by health policy makers, particularly those in developing countries. However, there is lack of literature that describes and evaluates priority setting in these contexts. The objective of this paper is to describe priority setting in a teaching hospital in Uganda and evaluate the description against an ethical framework for fair priority setting processes--Accountability for Reasonableness. METHODS: A case study in a 1,500 bed national referral hospital receiving 1,320 out patients per day and an average budget of 13.5 million US dollars per year. We reviewed documents and carried out 70 in-depth interviews (14 health planners, 40 doctors, and 16 nurses working at the hospital). Interviews were recorded and transcribed. Data analysis employed the modified thematic approach to describe priority setting, and the description was evaluated using the four conditions of Accountability for Reasonableness: relevance, publicity, revisions and enforcement. RESULTS: Senior managers, guided by the hospital strategic plan make the hospital budget allocation decisions. Frontline practitioners expressed lack of knowledge of the process. RELEVANCE: Priority is given according to a cluster of factors including need, emergencies and patient volume. However, surgical departments and departments whose leaders "make a lot of noise" are also prioritized. Publicity: Decisions, but not reasons, are publicized through general meetings and circulars, but this information does not always reach the frontline practitioners. Publicity to the general public was through ad hoc radio programs and to patients who directly ask. Revisions: There were no formal mechanisms for challenging the reasoning. Enforcement: There were no mechanisms to ensure adherence to the four conditions of a fair process. CONCLUSION: Priority setting decisions at this hospital do not satisfy the conditions of fairness. To improve, the hospital should: (i) engage frontline practitioners, (ii) publicize the reasons for decisions both within the hospital and to the general public, and (iii) develop formal mechanisms for challenging the reasoning. In addition, capacity strengthening is required for senior managers who must accept responsibility for ensuring that the above three conditions are met.

Decision Making, Organizational↗
PubMed2006

Priority setting and cardiac surgery: a qualitative case study.

PURPOSE: The purpose of this study is to describe priority setting in cardiac surgery and evaluate it using an ethical framework, "accountability for reasonableness". INTRODUCTION: Cardiac surgery is an expensive part of hospital budgets. Priority setting decisions are made daily regarding ever increasing volumes of patients. While much attention has been paid to the management of cardiac surgery waiting lists, little empirical research exists into the way actual decision makers deliberate upon and resolve priority setting decisions on a daily basis. A key goal of priority setting, in cardiac surgical areas as well as others, is fairness. "Accountability for reasonableness" is a leading ethical framework for fair priority setting, and can be used to identify opportunities for improvement (i.e. make it fairer) and highlight good practices. METHODS: A case study was conducted to examine the process of priority setting processes at three University of Toronto affiliated cardiac surgery centres. Relevant documents were examined, weekly triage rounds were observed for 27 months, and interviews were carried out with 23 key participants including cardiac surgeons, cardiologists, and triage nurses. In data analysis, the conditions of "accountability for reasonableness" (relevance, publicity, appeals and enforcement) were used as an analytic lens. RESULTS RELEVANCE: While decisions may appear to be based strictly upon clinical criteria (e.g. coronary anatomy); non-clinical criteria also have an impact upon decision-making (e.g. patients' lifestyle choices, type of surgical practice and departmental constraints on resource use). Participants stated that these factors influence their decision-making and can result in unfair and inconsistent decisions. PUBLICITY: Non-clinical reasons are not publicly accessible, nor are they clearly acknowledged in discussions between cardiac clinicians. APPEALS: There are mechanisms for challenging decisions however without access to the non-clinical reasons, this can be problematic. Enforcement: Participants cite little departmental or institutional support to engage in fairer priority setting. CONCLUSIONS: To our knowledge, this is the first study to describe actual priority setting practices for cardiac surgery practices and evaluate them using an ethical framework, in this case, "accountability for reasonableness". Priority setting decision making in cardiac surgery has been described and evaluated with lessons learned include specific findings regarding the contextual and dynamic nature of decision making in cardiac surgery. The approach of combining a descriptive case study with the ethical framework of "accountability for reasonableness" is a useful tool for identifying good practices and highlighting areas for improvement. The good practices (including surgeons strongly facilitating patients seeking second opinions and approaching patients from a holistic perspective in consideration for surgery) and areas for improvement (including lack of transparency and lack of institutional support for "fair" decision making) that we have identified in this case study can be used to reflect upon the present tool used in priority setting and improve the fairness and legitimacy of priority setting decision making in cardiac surgery.

Decision Making↗
PubMed2006

The Global Fund Secretariat's suspension of funding to Uganda: how could this have been avoided?

In August 2005, the Global Fund to fight AIDS, Tuberculosis and Malaria (the Global Fund) Secretariat suspended its five grants to Uganda following a PricewaterhouseCoopers audit report that exposed gross mismanagement in the Project Management Unit. How could this have been avoided? How can other countries avoid a similar pitfall? We argue that if a legitimate and fair decision-making process were used, the suspension of funding to Uganda could have been avoided, and that this lesson should be applied to other countries. The "accountability for reasonableness" framework of relevance, publicity, revisions and enforcement would help in implementing legitimate and fair decision-making processes, which would improve effectiveness, accountability and transparency in the implementation of Global Fund programmes, preventing future suspension of funding to any Global Fund projects.

Communicable Disease Control↗
PubMed2005

Leadership and priority setting: the perspective of hospital CEOs.

The role of leadership in health care priority setting remains largely unexplored. While the management leadership literature has grown rapidly, the growing literature on priority setting in health care has looked in other directions to improve priority setting practices--to health economics and ethical approaches. Consequently, potential for improvement in hospital priority setting practices may be overlooked. A qualitative study involving interviews with 46 Ontario hospital CEOs was done to describe the role of leadership in priority setting through the perspective of hospital leaders. For the first time, we report a framework of leadership domains including vision, alignment, relationships, values and process to facilitate priority setting practices in health services' organizations. We believe this fledgling framework forms the basis for the sharing of good leadership practices for health reform. It also provides a leadership guide for decision makers to improve the quality of their leadership, and in so doing, we believe, the fairness of their priority setting.

Attitude of Health Personnel↗
PubMed2005

Theatre as a public engagement tool for health-policy development.

PURPOSE: To explore theatre as a public engagement tool for health-policy development. BACKGROUND: In a justice-based democracy, engagement of a large number of citizens of diverse perspectives is required for legitimate health-policy development. However, all current strategies of citizen participation are limited in their capacity to engage, either by lack of opportunity to educate citizens prior to soliciting their opinions or lack of large numbers of citizens. METHODS: A series of 12 nested case studies was conducted, with each case study consisting of a performance of a 70-min play, specifically written to educate citizens to scientific, clinical, and psychosocial issues of adult predictive genetic testing, and to foster empathy for persons immersed therein; and a 1-h audience discussion that was taped and transcribed for qualitative analysis (modified thematic). The script was based on key informant interviews, literature review, and six script readings for key informants and communities. Audience members were recruited through conference or educational event programs, posters, newsletters, and electronic announcements, as well as newspaper advertisements and other public, community and institutional postings. RESULTS: More than 1,000 citizens were engaged. The analysis indicated that audience members were engaged emotionally and cognitively in the position of the characters and the health-policy issues. Audience members' comments forwarded from personal or professional lived experience confirmed the validity of the script and promoted further emotional and cognitive engagement of other audience members. Audience members offered informed and diverse opinions on policy issues, including resource allocation, patenting of genetic tests, research funding, genetic test-based insurance discrimination, and imperative for public education. The potential for harm to key informants and audience members (and those in relationships with them) were observed, usually related to learning or offering personal information regarding their genetic risk. CONCLUSION: As many citizens can be engaged in theatre-based policy development as surveyed through public opinion polls, and many times the number that can be engaged in strategies that educate citizens prior to soliciting their opinions, likely at a similar cost per citizen engaged.

Community Participation↗
PubMed2005

Communication of bed allocation decisions in a critical care unit and accountability for reasonableness.

BACKGROUND: Communication may affect perceptions of fair process for intensive care unit bed allocation decisions through its impact on the publicity condition of accountability for reasonableness. METHODS: We performed a qualitative case study to describe participant perceptions of the communication of bed allocation decisions in an 18-bed university affiliated, medical-surgical critical care unit at Sunnybrook and Women's College Health Sciences Centre. Interviewed participants were 3 critical care physicians, 4 clinical fellows in critical care, 4 resource nurses, 4 "end-users" (physicians who commonly referred patients to the unit), and 3 members of the administrative staff. Median bed occupancy during the study period (Jan-April 2003) was 18/18; daily admissions and discharges (median) were 3. We evaluated our description using the ethical framework "accountability for reasonableness" (A4R) to identify opportunities for improvement. RESULTS: The critical care physician, resource nurse, critical care fellow and end-users (trauma team leader, surgeons, neurosurgeons, anesthesiologists) functioned independently in unofficial "parallel tracks" of bed allocation decision-making; this conflicted with the official designation of the critical care physician as the sole authority. Communication between key decision-makers was indirect and could exclude those affected by the decisions; notably, family members. Participants perceived a lack of publicity for bed allocation rationales. CONCLUSION: The publicity condition should be improved for critical care bed allocation decisions. Decision-making in the "parallel tracks" we describe might be unavoidable within usual constraints of time, urgency and demand. Formal guidelines for direct communication between key participants in such circumstances would help to improve the fairness of these decisions.

Attitude of Health Personnel↗
PubMed2005

Priority setting in hospitals: fairness, inclusiveness, and the problem of institutional power differences.

Priority setting tends to take place in health care settings that are hierarchical and politically complex. Fair processes, as defined for example by Daniels' and Sabin's accountability for reasonableness framework, have been identified as essential for securing socially acceptable priority setting decisions. However, power differences in the decision-making context can pose a serious impediment to fair priority setting in health care organizations. Comparatively little attention has been paid to examining the institutional conditions within which priority setting decisions are made. We review a case study of priority setting in hospital operational planning in Toronto, which had been designed by executive leaders to be broadly inclusive of senior and middle-level clinical and administrative leaders. We report three power differences that arose as limiting factors on the inclusiveness of the priority setting process. We argue that these findings have significant theoretical implications for the accountability for reasonableness framework and propose a fifth condition, the "empowerment condition", which states that there should be efforts to minimise power differences in the decision-making context and to optimise effective opportunities for participation in priority setting.

Decision Making, Organizational↗
PubMed2005

An ethical framework for cardiac report cards: a qualitative study.

BACKGROUND: The recent proliferation of health care report cards, especially in cardiac care, has occurred in the absence of an ethical framework to guide in their development and implementation. An ethical framework is a consistent and comprehensive theoretical foundation in ethics, and is formed by integrating ethical theories, relevant literature, and other critical information (such as the views of stakeholders). An ethical framework in the context of cardiac care provides guidance for developing cardiac report cards (CRCs) that are relevant and legitimate to all stakeholders. The purpose of this study is to develop an ethical framework for CRCs. METHODS: Delphi technique - 13 panelists: 2 administrators, 2 cardiac nurses, 5 cardiac patients, 2 cardiologists, 1 member of the media, and 1 outcomes researcher. Panelists' views regarding the ethics of CRCs were analyzed and organized into themes. RESULTS: We have organized panelists' views into ten principles that emerged from the data: 1) improving quality of care, 2) informed understanding, 3) public accountability, 4) transparency, 5) equity, 6) access to information 7) quality of information, 8) multi-stakeholder collaboration, 9) legitimacy, and 10) evaluation and continuous quality improvement. CONCLUSION: We have developed a framework to guide the development and dissemination of CRCs. This ethical framework can provide necessary guidance for those generating CRCs and may help them avoid a number of difficult issues associated with existing ones.

Access to Information↗
PubMed2005

What do hospital decision-makers in Ontario, Canada, have to say about the fairness of priority setting in their institutions?

BACKGROUND: Priority setting, also known as rationing or resource allocation, occurs at all levels of every health care system. Daniels and Sabin have proposed a framework for priority setting in health care institutions called 'accountability for reasonableness', which links priority setting to theories of democratic deliberation. Fairness is a key goal of priority setting. According to 'accountability for reasonableness', health care institutions engaged in priority setting have a claim to fairness if they satisfy four conditions of relevance, publicity, appeals/revision, and enforcement. This is the first study which has surveyed the views of hospital decision makers throughout an entire health system about the fairness of priority setting in their institutions. The purpose of this study is to elicit hospital decision-makers' self-report of the fairness of priority setting in their hospitals using an explicit conceptual framework, 'accountability for reasonableness'. METHODS: 160 Ontario hospital Chief Executive Officers, or their designates, were asked to complete a survey questionnaire concerning priority setting in their publicly funded institutions. Eight-six Ontario hospitals completed this survey, for a response rate of 54%. Six close-ended rating scale questions (e.g. Overall, how fair is priority setting at your hospital?), and 3 open-ended questions (e.g. What do you see as the goal(s) of priority setting in your hospital?) were used. RESULTS: Overall, 60.7% of respondents indicated their hospitals' priority setting was fair. With respect to the 'accountability for reasonableness' conditions, respondents indicated their hospitals performed best for the relevance (75.0%) condition, followed by appeals/revision (56.6%), publicity (56.0%), and enforcement (39.5%). CONCLUSIONS: For the first time hospital Chief Executive Officers within an entire health system were surveyed about the fairness of priority setting practices in their institutions using the conceptual framework 'accountability for reasonableness'. Although many hospital CEOs felt that their priority setting was fair, ample room for improvement was noted, especially for the enforcement condition.

Attitude of Health Personnel↗
PubMed2005

Evidence, economics and ethics: resource allocation in health services organizations.

Priority setting is a challenge for health services organizations across health systems. Because demand for health services exceeds available resources, health services priorities must be set to ensure resources are used appropriately to meet the community's health needs. Various approaches have been developed to assist decision-makers to set priorities in their organizations. The dominant approaches come from evidence-based medicine, economics and ethics.

Canada↗
PubMed2005

Patients' views about cardiac report cards: a qualitative study.

BACKGROUND: Health care report cards provide stakeholders with information on health care outcomes and other measures of care, and they are most well developed in cardiac care. A necessary first step to ground the development of cardiac report cards (CRCs) is to incorporate the views of stakeholders. Although the views of experts have been described, the views of cardiac patients, arguably the most important stakeholders, have not yet been described. OBJECTIVE: To describe cardiac patients' views about CRCs. METHODS: Qualitative interviews were conducted with 91 cardiac patients contacted from seven Canadian cardiac care centres. Participants' views regarding CRCs were analyzed and organized into themes. RESULTS: Participants' views were organized into four themes: overall views, purpose, content and dissemination. Participants expressed overwhelmingly positive views about CRCs and thought that CRCs should be used to improve the quality of cardiac care, enhance accountability and improve informed decision-making. They said that they would use CRCs that contained information relevant to patients -- in particular, information about other cardiac patients' experiences. They described a patient-derived framework for the content of CRCs. Participants also described dissemination formats and vehicles that would increase the usefulness of CRCs. CONCLUSIONS: The cardiac patients in the present study had positive attitudes about CRCs and would use them if they were designed to be relevant to patients. In particular, the participants wanted CRCs to provide information about other cardiac patients' experiences.

Adult↗
PubMed2004

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

BACKGROUND: 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. 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'. METHODS: This 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. RESULTS: Participants 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.

Attitude of Health Personnel↗
PubMed2004

Hospital priority setting with an appeals process: a qualitative case study and evaluation.

OBJECTIVE: To describe and evaluate priority setting in the context of hospital priority setting and more specifically to evaluate the use of an appeals process. DESIGN: Qualitative case study and evaluation using the ethical framework 'accountability for reasonableness'. SETTING: The University Health Network (UHN), a network of three large urban teaching hospitals affiliated with the University of Toronto in Toronto, Canada. This study focused on Clinical Activity Target Setting (CATS), the final component of the strategic planning process. PARTICIPANTS: Sixty-six board members, senior administrators, managers, clinical leaders and other hospital staff who participated in the hospital strategic planning exercise. DATA COLLECTION: Three primary sources of data were used: key documents, interviews with participants and stakeholders and observations of group deliberations. DATA ANALYSIS: Open and axial coding using an explicit conceptual framework 'accountability for reasonableness'. RESULTS: This was the first time an appeal process has been described and evaluated. The appeals process was found to be a fundamental component to overall perceived fairness of the priority setting process. The appeals process also enhanced the involvement of stakeholders and increased overall participant satisfaction. In addition, four areas of 'good practice' and ten recommendations for improvement of the larger priority setting process were identified. CONCLUSIONS: This case study has provided an in-depth analysis of a priority setting process at a hospital, with a particular focus on the appeals process. Also, we compared the lessons learned from this study with those from a previous study at a different hospital.

Attitude of Health Personnel↗
PubMed2004

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

BACKGROUND: Hospitals 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. DISCUSSION: We 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. SUMMARY: Lessons 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.

Academic Medical Centers↗
PubMed2004

Can a "good death" be made better?: A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients.

BACKGROUND: Prior studies attempting to improve end-of-life care have focused on specific outcomes deemed important to healthcare providers, with disappointing results. Improvement may be best achieved by identifying concerns important to individual patients, communicating the patients' concerns to the treating medical team, and repeating the process frequently until all concerns are addressed. Our objective was to conduct a preliminary evaluation of this innovative patient-centred quality improvement strategy. METHODS: Initial interviews elicited participants' ideas for improvement, which were then fed back to health care providers by the study investigator. A rapid-cycle change model ensured frequent reassessment and continued feedback. The study involved 36 seriously ill, hospitalized patients on teaching general medical inpatient units of a tertiary care hospital. The main outcome measure was participants' ratings of satisfaction within different domains of care on follow-up interviews. RESULTS: The proportion of participants who rated various aspects of their care as "excellent" or "very good" on initial interview was 72% for overall care, 64% for symptom control, 66% for level of support, and 75% for discussions about life sustaining treatments. Patients and families identified many actionable steps for improvement such as; better control of pain and shortness of breath, better access to physicians and medical information, more help with activities of daily living, improving the patient's environment, and shorter waits for nursing care, diagnosis, and treatment. Following feedback to the clinical team, participants reported improvement in overall care (32%), symptom control (44%), and support (40%). Only a minority had further discussions about life sustaining treatments. CONCLUSION: A patient-centred approach using rapid-cycle change was feasible and shows promise for improving the quality of end-of-life care. It should be evaluated on a larger sample in a controlled trial.

Journal Article↗