政治自由主义 = Political liberalism

The sustainability of healthcare systems worldwide is threatened by a growing demand for services and expensive innovative technologies Decision makers struggle in this environment to set priorities appropriately, particularly because they lack consensus about which values should guide their decisions One way to approach this problem is to determine what all relevant stakeholders understand successful priority setting to mean The goal of this research was to develop a conceptual framework for successful priority setting Three separate empirical studies were completed using qualitative data collection methods (one-on-one interviews with healthcare decision makers from across Canada; focus groups with representation of patients, caregivers and policy makers; and Delphi study including scholars and decision makers from five countries) This paper synthesizes the findings from three studies into a framework of ten separate but interconnected elements germane to successful priority setting: stakeholder understanding, shifted priorities/reallocation of resources, decision making quality, stakeholder acceptance and satisfaction, positive externalities, stakeholder engagement, use of explicit process, information management, consideration of values and context, and revision or appeals mechanism The ten elements specify both quantitative and qualitative dimensions of priority setting and relate to both process and outcome components To our knowledge, this is the first framework that describes successful priority setting The ten elements identified in this research provide guidance for decision makers and a common language to discuss priority setting success and work toward improving priority setting efforts

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Priority setting: what constitutes success? A conceptual framework for successful priority setting

Setting limits fairly: can we learn to share medical resources?

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

Although rationing of scarce health-care resources is inevitable in clinical practice, there is still limited and scattered information about how physicians perceive and execute this bedside rationing (BSR) and how it can be performed in an ethically fair way. This review gives a systematic overview on physicians' perspectives on influences, strategies, and consequences of health-care rationing. Relevant references as identified by systematically screening major electronic databases and manuscript references were synthesized by thematic analysis. Retrieved studies focused on themes that fell under three major headings: (i) conditions and influences of BSR, (ii) strategies of BSR, and (iii) consequences of BSR. The range of themes indicates that physicians' rationing behavior is highly variable, strongly influenced by context-related factors, and consists mainly of implicit rationing strategies. Torn between patient advocacy and the obligation to contain costs, physicians experience various role conflicts. The development of explicit rationing strategies seems necessary to avoid arbitrary BSR and allow a fair allocation of health-care resources.

How Physicians Allocate Scarce Resources at the Bedside: A Systematic Review of Qualitative Studies

Leadership and priority setting: The perspective of hospital CEOs

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'. 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. 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%). 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.

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

Governments can be accountable for improving the fairness of their priority setting through enhanced transparency and stakeholder engagement. A case analysis is conducted of priority setting in a government health care context in Ontario, Canada, assessing how implementation of hospital accountability agreements meets the conditions of a leading international ethical framework for priority setting, “accountability for reasonableness” (A4R). Hospital accountability agreements provide a mechanism for government to ensure that public funding achieves desired performance in hospitals. A key goal of priority setting is fairness. A4R links priority setting, legitimacy, and fairness to theories of democratic deliberation, making a claim for fairness if the four conditions of relevance, publicity, revision/appeals, and enforcement are satisfied. Regarding the relevance condition, this analysis suggests that government only partially met the relevance condition providing limited stakeholder engagement but with evidence of policy learning and movement toward the establishment of inclusive stakeholder arrangements. Evidence suggests that government eventually progressed toward meeting the publicity condition. Government only partially met the revision/appeals condition and did not meet the enforcement condition, as the other conditions were only partially met. It is our view that regional governance structures in Ontario (i.e., Local Health Integration Networks or LHINs) provide an opportunity for the province to improve the fairness of their accountability agreement processes through enhancing transparency and stakeholder engagement. More broadly, this case study provides a guide for government to enhance accountability by focusing on A4R to improve the fairness of its priority setting.

David Reeleder

Papers

Leadership and priority setting: The perspective of hospital CEOs

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

Accountability Agreements in Ontario Hospitals: Are They Fair?