Table I.
The decision-making audit tool
| Description | Prompt questions | Audit question | |
|---|---|---|---|
| Process values | |||
| Institutional setting | Before you consider how best to respect social values and other criteria of decision making, you need first to consider the role that your organisation (or the one you are auditing) plays in the wider institutional context of health care decision making | What legal responsibilities does your organisation have with regards to health care resource allocation? What legal obligation is your organisation under to avoid discrimination, promote equality and diversity and match resources to population needs? |
On a scale from 1 to 5 how sure are you that your organisation has systems in place to identify and address its legal responsibilities? (1: representing very unsure, 2: somewhat unsure, 3: undecided, 4: sure, 5: very sure) |
| Transparency | Those who commission health care are given considerable power and with power comes responsibility. Being transparent in their decision making is one way in which organisations can assure themselves that they are not making decisions on grounds that are considered unfair or biased by the wider public | How clearly does your organisation offer reasons for decisions? When your organisation is faced with a difficult decision, has it been open about the difficulties with those who will ultimately be affected by the decisions? |
On a scale from 1 to 5 how sure are you that your organisation can demonstrate that it offers understandable and accessible reasons for its decisions? (1: representing very unsure, 2: somewhat unsure, 3: undecided, 4: sure, 5: very sure) |
| Accountability | Those who commission health care have a great number of people and organisations to whom they are accountable. Sometimes accountability if formal, involving legal or financial accountability. Sometimes it is less formal, for example, to colleagues or local media outlets. In all cases accountability requires an ability to give reasons for one’s decisions | Has your organisation identified to whom it is formally and informally accountable? Does your organisation provide an account of the reasons for its decisions in a variety of formats so that those who are less used to reading long and complex documents can follow them? |
On a scale from 1 to 5 how sure are you that your organisation can demonstrate that it is accountable? (1: representing very unsure, 2: somewhat unsure, 3: undecided, 4: sure, 5: very sure) |
| Participation | Participation of stakeholders and the wider public is important because it adds to the views and values that are considered when making decisions. Enabling different groups, e.g. patients, the public, health professional and elected officials, to contribute to decision making ensures that these different views are heard and special needs are understood | Whom does your organisation include in its decision-making process and how? What is the goal of the participation method your organisation has chosen (e.g. deliberation, consultation, elicitation of public preferences)? How are the results of participation exercises incorporated in decision making and how is this communicated to the participants? |
On a scale from 1 to 5 how sure are you that your organisation can demonstrate that it ensures participation of relevant stakeholders and the wider public? (1: representing very unsure, 2: somewhat unsure, 3: undecided, 4: sure, 5: very sure) |
| Content values | |||
| Effectiveness | Effectiveness is a necessary condition for the provision of good health and social care. No one should allocate resources to forms of care that do no good or do harm. However, knowing what is effective is not easy, especially in the absence of evidence in the form of clinical effectiveness studies in some areas of health care provision | Is there a system in place to identify the evidence for the effectiveness of commissioned services? How, and by whom, is effectiveness evidence being assessed and appraised? How are decisions made in the absence of evidence (note: absence of evidence is not the same as evidence of ineffectiveness)? |
On a scale from 1 to 5 how sure are you that your organisation can demonstrate that it assesses effectiveness? (1: representing very unsure, 2: somewhat unsure, 3: undecided, 4: sure, 5: very sure) |
| Cost effectiveness | Cost-effectiveness judgements centred around “value for money” can be controversial. For some it means that there is a risk that financial considerations could be put before patients’ needs. For others it means that the needs of all patients, rather than a few, are considered and that the best possible care for the largest number of patients is secured | Is there a system in place to identify national guidance or standards such as NICE recommendations? Have you taken steps to assure that what you are commissioning is cost effective? How are decisions made in the absence of evidence for cost effectiveness? |
On a scale from 1 to 5 how sure are you that your organisation can demonstrate that it assesses cost effectiveness? (1: representing very unsure, 2: somewhat unsure, 3: undecided, 4: sure, 5: very sure) |
| Fairness | Fairness goes by different names. Some people talk about equity and others about human rights. In the area of health care prioritisation fairness relates to the question whether all those who use health care services are treated with equal concern and respect | How are vulnerable patient groups identified in your area and how do you ensure adequate services for these groups? Are services commissioned only on the basis of need and not on other characteristics such as age, gender, ethnicity or sexual orientation? |
On a scale from 1 to 5 how sure are you that your organisation can demonstrate that it is fair to all population and patient groups on whose behalf it is commissioning services? (1: representing very unsure, 2: somewhat unsure, 3: undecided, 4: sure, 5: very sure) |
| Solidarity | Solidarity is the principle that “we are all in it together”. This value implies that costs for health care will be covered collectively in order to secure access to health care for individuals | Are services accessible for all, e.g. are there mechanisms in place to cover travel and other costs of access? Does your commissioning strategy create a situation in which some people have to fund elements of treatments from their own pockets in ways that are unduly burdensome? |
On a scale from 1 to 5 how sure are you that your institutions can demonstrate that it addresses the social value of solidarity? (1: representing very unsure, 2: somewhat unsure, 3: undecided, 4: sure, 5: very sure) |