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

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.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.'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.As of August 12, 2003 there were 438 probable and suspected cases of Severe Acute Respiratory Syndrome (SARS) in Canada – the majority located in Toronto. 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 setting (also known as rationing or resource allocation) within hospitals is crucial. 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 SARS in Toronto in 2003, amplifies the difficulties of hospital priority setting.Key goals of priority setting in any context are legitimacy and fairness. 'Accountability for reasonableness' is an explicit ethical framework for legitimate and fair priority setting in he