Resource Allocation in Health Care Exercise

Integrating Ethical Reflection Into Practice Meso (Program-Level) Resource Allocation Exercise Bashir Jiwani, PhD

Background and Justification

A decision is always made in one direction over another because the chosen direction responds to or achieves something that is seen as important. For example, resources are invested into training people and resourcing programs that can respond to emergencies in the community (police, fire, paramedics), because the prevention of unnecessary death and minimization of unfair or unnecessary suffering is seen as important.

Whatever is considered important is effectively a reflection of the values of the decision maker. Saving life, ensuring people are treated fairly, upholding the law, and preventing needless suffering are all values.

For individuals, teams, institutions, and organizations to live with integrity requires that the decisions they make be based on well-considered and justified values. In the context of a complex public good serving a pluralistic community with unequal resources and unequal access to services and corridors of authority (such as health care in Canada), living with integrity is especially important and especially difficult. If decision makers don’t reflect critically and systematically on the values behind their decisions, there is greater risk of:  Inconsistent decision making throughout the system  Compromise of individual, team, institution, and organization integrity  Increase experience of moral distress throughout the organization (anxiety, frustration, anger over living with decisions that go against values considered very important)  Increase confusion about future right direction

If the values-based justification of decisions is not made transparent, there is greater risk of:  Incomplete buy-in to organizational direction  Decrease in compliance with higher level decisions

The Task1

As a member of the executive for a health region, you are charged with the responsibility of providing health care services for a population exceeding 1 million people. In response to the region’s health services plan for 2008/2009, the province has provided a $7.5 million increase in funding for the year. All efforts at increasing efficiencies and resource development have been exhausted. In this fiscal year you are running a deficit and you have “borrowed” $3 million from the budgets for projects to begin in future years, to help finance this. Some of the newer programs you have recently initiated are also not fully funded. You and your executive team must decide how to allocate the growth that the province has approved. Aside from the announcement for funding, the government has offered a great deal of direction as to what priorities the region should have. Key environmental issues include serious demand pressures on beds, congestion in emergency departments, and unfunded bed capacity in community care.

The programs listed below are a sample of the $33.5 million in program growth that has been identified, but again, only $7.5 million is available

This exercise you to complete two forms: 1) Budget allocation form: Allocate the money amongst these programs (No outside the box thinking for this exercise! It is just meant to help reflect on the second task) 2) Reflect on and articulate the criteria you used to judge the value of the different programs?

1Prepared by Bashir Jiwani (2006). Adapted from Larry Churchill, Rationing Healthcare in America. Indiana: University of Notre Dame Press. 1987. Acknowledgements to Bark Kong, Patricia Petryshen, and Brian Woods, Fraser Health. 1/3 Integrating Ethical Reflection Into Practice Meso (Program-Level) Resource Allocation Exercise Bashir Jiwani, PhD

Exercise #1: Budget Allocation Form

) n e g

Sample Initiative o m n i m i t $ i t ( a t

c r r e o a e n l e l p y O a o

) t r l s a u m r ( i u o

Y s r n o o f A c

) l a m t $ o (

T t s o c Support for cardiac stent program – best practice in cardiac care, physicians have 1 2 3 __m training to perform and are passionate about, will benefit approximately 100 people. Increase funding to the orthopedic surgery program to shorten waiting lists for hip 2 1.5 3.5 __m replacement surgery and meet MOH directive. (Waiting list is currently 10 - 12 months.) Expand community care/ home support services for the vulnerable elderly to 1.5 1 2.5 __m provide nutrition, social support, and accident/injury prevention services. Software to track incidents where patient safety compromised. 2 1 3 __m Increase obstetrics budget to match new birth rates (300 births budgeted for, 2 3 5 __m upwards of 700 likely). Increase budget for trauma to match likely expenditure required. 2 2 4 __m Open planned but cancelled ICU beds. 1 1.5 2.5 __m Increase funding for cataract surgery to meet federal waitlist targets. (Waiting list 1 1 2 __m is currently 10 months.) Increase funding for open heart surgery to meet federal waitlist targets. (Waiting 1 1.5 2.5 __m list is currently 10 months.) Increase budget for pediatrics to match growth in pediatric population. 3.5 2 5.5 __m

Total 17m 16.5m 33.5m __m

2/3 Integrating Ethical Reflection Into Practice Meso (Program-Level) Resource Allocation Exercise Bashir Jiwani, PhD

Exercise #2: Criteria Form

Criterion Rationale Priority On a scale of 1 (crucial) to 5 In allocating our resources we should support It is important to use this criterion (important), I would initiatives that demonstrably… because… give this criterion a priority ranking of… Improve the long-term outcomes for young patients. Improve the short-term outcomes for elderly patients. Support new innovation. Minimize the harm done by the system. Return to full function in the longer term. Return to previous function but with some physical or cognitive disability in the longer term. Help patients recover, but only for a short time. Minimize patient suffering.