Community Benefit - Add Ethical Decision-Making to the Planning Process

July-August 2014


The emergency department's nurses and physicians identified the problem: Too many women were coming to the ER in active labor without having had the benefit of prenatal care. As a result, many of those women had complicated deliveries and/or delivered low-birth-weight babies needing intensive care. Women's health and the health of newborns were at risk.

The information about this situation became part of one Catholic hospital's community health needs assessment and community benefit plan, referred to in the Internal Revenue Service (IRS) rules as the implementation strategy. It also became the start of an ethical decision-making process that involved input from and consequences for the hospital and its staff, the women at risk and other partners in the community to reach the best possible solution.

Ethical decision-making is a systematic and critical reflection on moral choices. It usually involves six steps:

  1. Gather information
  2. Identify the issue
  3. Review core commitments
  4. Identify the alternatives
  5. Make a decision
  6. Evaluate the decision

The first step, gathering information, calls for assembling facts, identifying stakeholders and their views and analyzing relevant social, economic and other factors. The community benefit team began collecting information on why women were not receiving the prenatal care they needed. An analysis of the ER admissions indicated that most of these women were either uninsured or Medicaid beneficiaries. A focus group of new mothers who had not received prenatal care revealed that they knew about the importance of such care but did not know how to access it, and they could not afford it. The team determined that statistically, the community had an adequate number of obstetricians, but few accepted Medicaid or uninsured patients.

Community benefit planning involves identifying what the IRS calls significant needs and, from the list of significant needs, identifying a smaller number of prioritized needs to be addressed by the hospital. The need for affordable and accessible prenatal care and education was considered significant by the community benefit committee made up of representatives from the hospital, health department and residents from a low-income family housing complex.

But was it a priority, an issue that should be addressed by the hospital? There were many competing health needs in this community. Was this one of the most pressing problems?

In ethical decision-making, the second step, identifying the issue, calls for asking: What are the values behind various positions? Are any values in conflict?

The committee used a set of criteria to examine the issue of prenatal care. These criteria could be seen as an expression of the committee's values:

  • How many people are involved?
  • Is the problem getting worse?
  • How serious is the problem?
  • What would happen if we did not act?
  • Are low-income people particularly affected?
  • Is this an important issue to our community?

The answers to these questions led the committee to identify the need for more prenatal care as a priority for the hospital to address.

To review core commitments, the third step, the hospital representatives of the committee reflected on: What values do we claim to espouse? What guidance is provided by our faith? Are other moral principles involved?

Ever since it was first established more than 150 years ago, this hospital has focused on care of economically poor women and the health of children in low-income families. Its mission statement speaks to the hospital's commitment to ensuring access to quality health care. Church teaching compels the hospital to respect the dignity of each person, to reach out to vulnerable persons and to be good stewards of resources.

These core commitments also supported making prenatal care for low-income women a priority.

Ethical decision-making in community benefit planning continued, once the issue was identified as a priority to be addressed. In Step 4, identifying alternatives, the following strategies were considered:
  • Hiring several obstetricians to care for uninsured and Medicaid patients was certainly a possibility, but it was too expensive for the hospital to pursue.
  • Working with the county health department to develop county-run clinics. Unfortunately, this county's local health department was reducing its direct care services.
  • Referring low-income pregnant women to a federally qualified health center. However, the nearest clinic was not convenient to where most patients lived.
  • Hiring a nurse midwife who could manage more of the prenatal care and to arrange with a local graduate school of nursing to have students make home visits and follow up the work of the nurse midwife.
Making the decision, called for in Step 5, was not difficult. The use of a nurse midwife with advanced practice nursing students made a lot of sense. It would make prenatal care available to a large number of maternity patients, and outreach, through the nursing students, would extend to potential users and provide needed follow-up.

Meetings were held with administration, obstetrical medical staff, the finance office, the school of nursing and with community groups. The decision was a popular one — full of promise.

After six months, it was time for Step 6, evaluating the decision. What had been the impact of the decision on the organization's core commitments and on its constituencies? If the outcome has not been as positive as hoped for, why?

In this case, the outcome was mixed. Enrollment in the program was better than expected. Patient outcomes were excellent, with fewer maternal and newborn complications. The patients, obstetricians and students were enthusiastically supportive.

But financially the program was challenged. The nurse midwife, while highly educated in her field and compassionate, had little experience in program budgeting. The program turned out to be much more expensive than expected.

What to do? It was time to go back to the ethical decision-making steps:

  • Gather information
  • Identify the issue
  • Review core commitments
  • Identify the alternatives
  • Make a decision
  • Evaluate the decision

The program was successful clinically, but not financially. Most of the stakeholders were supportive, but economically it was not working.

Identify the issue: Values were in conflict such that the responsibility to be good stewards of resources was at odds with the values of respect for the patients needing care, concern for low-income patients and commitment to excellence. There also was conflict within the issue of stewardship: The hospital could not continue to afford the program, but overall the cost of caring for the women and newborns was lower with the nurse midwife solution than it might have been with other alternatives. It also was less expensive than caring for pregnant women in the emergency department and infants in intensive care.

Review core commitments: The program was meeting the organization's core commitment toward respect, care of the poor and excellence. It was continuing the tradition of serving low-income women and protecting the health of newborns. However, it was not stewarding resources as well as it could or should.

Identify the alternatives: All options were put on the table: Reduce the size of the program or eliminate it altogether; transfer it to another agency; or try to make it more efficient. The community benefit committee asked: What would be the short- and long-term consequences of each alternative? Which alternative was most consistent with what the organization claims to be?

Make a decision: It was decided that making the program viable could lead to the most positive outcome and that keeping the program was the right thing to do. The chief financial officer made a commitment to work closely with the nurse midwife and her staff and brought in a part-time manager for overall and day-to-day budgeting.

Evaluate the decision: The program continues to be evaluated for quality, budget and outcome.

For this hospital, community benefit planning and ethical decision-making worked — and it was the right thing to do.

SR. PATRICIA TALONE, RSM, is vice president, mission services, Catholic Health Association, St. Louis.

JULIE TROCCHIO is senior director, community benefit and continuing care, Catholic Health Association, Washington, D.C.

Community Benefit-Add Ethical Decision-Making to the Planning Process

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