Hearns, Klein and colleagues set out to develop a maternity care decision-making tool for the British Columbia Northern Health Authority to assist with assessing community needs and values. They are to be commended for thinking outside the traditional decision-making approach which focuses, as they say, on "administration, fiscal and safety issues. Solutions often follow previously made decisions … [because] this approach is less time-consuming, simpler and safer." They go on to point out the problems with this approach, such as minimal engagement of community members or representation of their interests, potentially resulting in disempowerment and bitterness. They claim that their process rectifies this lack of engagement:

… through a structured process of identifying and evaluating alternatives, creative and defensible choices can be made in difficult decisional contexts that accommodate different capacities within communities. If these choices are done well, the stakeholders, communities and healthcare workers are more likely to be sympathetic, or at least understanding of decisions made. Moreover, the process helps ensure that creative alternatives are produced and evaluated in a transparent and unbiased manner.

Commentaire sur la mise au point d'un outil d'appui à la prise de décisions complexes

Hearns, Klein and colleagues set out to develop a maternity care decision-making tool for the British Columbia Northern Health Authority to assist with assessing community needs and values. They are to be commended for thinking outside the traditional decision-making approach which focuses, as they say, on "administration, fiscal and safety issues. Solutions often follow previously made decisions … [because] this approach is less time-consuming, simpler and safer." They go on to point out the problems with this approach, such as minimal engagement of community members or representation of their interests, potentially resulting in disempowerment and bitterness. They claim that their process rectifies this lack of engagement:

… through a structured process of identifying and evaluating alternatives, creative and defensible choices can be made in difficult decisional contexts that accommodate different capacities within communities. If these choices are done well, the stakeholders, communities and healthcare workers are more likely to be sympathetic, or at least understanding of decisions made. Moreover, the process helps ensure that creative alternatives are produced and evaluated in a transparent and unbiased manner.

The Decision Support Manual and its tools and processes are intended for use in low birth volume settings, and the authors have accomplished this and more. Changing demographics, a desire to maintain rural quality of life and economic challenges ensure that decision-making is likely to be more rather than less frequent for healthcare teams and administrators. Hence the need for tools and processes that ensure the most inclusive, transparent and action-focused approach to difficult decisions. Following such principles promotes the best opportunity for an outcome that satisfies community members that their ideas have been heard and that their needs have been addressed as well as possible. It would seem that in the long term, this approach is likely to be most acceptable to all involved and to promote the overall success of proposed changes to healthcare services where there are potentially conflicting interests.

This paper provides a detailed description of the development of the Decision Support Manual, Informed Decision-Making: The Interaction between Sustainable Maternity Care Services and Community Sustainability, which I had the privilege to preview. The manual itself provides instructions on use of the tool and a concise, simple, step-by-step nine-point approach to this complex decision-making process which appears to be practical and straightforward and offers many tips on enhancing its use.

The authors' informed decision-making process should be highly relevant to those in health policy positions who are looking for a more open and transparent way to resolve identified problems and issues to ensure that solutions have support, or at the very least, can be understood by local stakeholders who may be most affected by the change. The openness to involving non–health professional community stakeholders (child-bearing families, as well as cultural and business leaders) in the consultation process is particularly relevant to creating community buy-in and understanding. The authors correctly point out that not everyone may like the outcome of the process, but done in this transparent way all are heard; their voices have counted for something in the final product, and the reasons behind the choices made are understood and supported.

The authors have used a process that they designed to be value-based, informed, collaborative and transparent, and adaptive. They claim that it is intended to be reviewed, modified and updated in an iterative manner. However, they do not speak about what appears to me to be their wise incorporation of a holistic systems approach to rationalization of services, by implicitly acknowledging that reorganization, particularly reduction in services, involves and affects not just healthcare administration, personnel and facilities, but also cultural leaders, local business interests and families within the community.

Decision-makers – particularly, management and policy makers – are often challenged with difficult choices for care provision within their health authorities; consequently, they may want to try this tool to come up with acceptable alternatives within their regions, particularly those with diverse rural communities. The authors are correct to emphasize that rural maternity care is just one example of the tool's utility.

An important strength of this paper is the immediate relevance of the authors' process to the administrators making decisions. But it also addresses what many only espouse – inclusion of the input of key and multiple stakeholders at a grassroots decision-making level. The authors state that the health authority deemed the exercise successful, but it would also be good to see an evaluation of the communities subsequent to the changes to see whether understanding and satisfaction have actually increased with the decisions made. I would encourage the authors to do further research with other groups interested in service reallocation or reduction to test the model further.

This era of resource rationalization is a time of difficult choices for those who hold overall responsibility for our healthcare services. Tools that bring to the decision-making table local businesses and the needs of those who receive care are timely, and are bound to have more relevance to those people ultimately receiving and affected by regional health services. Such approaches are destined for the best opportunity for success. Those described here should be of interest to administrators, change agents and health policy professionals.

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