Purpose Using the example of community access programs (CAPs), the purpose of this paper is to describe resource allocation and policy decisions related to providing health services for the uninsured in the USA and the organizational values affecting these decisions. Design/methodology/approach The study used comparative case study methodology at two geographically diverse sites. Researchers collected data from program documents, meeting observations, and interviews with program stakeholders. Findings Five resource allocation or policy decisions relevant to providing healthcare services were described at each site across three categories: designing the health plan, reacting to funding changes, and revising policies. Organizational values of access to care and stewardship most frequently affected resource allocation and policy decisions, while economic and political pressures affect the relative prioritization of values. Research limitations/implications Small sample size, the potential for social desirability or recall bias, and the exclusion of provider, member or community perspectives beyond those represented among participating board members. Practical implications Program directors or researchers can use this study to assess the extent to which resource allocation and policy decisions align with organizational values and mission statements. Social implications The description of how healthcare decisions are actually made can be matched with literature that describes how healthcare resource decisions ought to be made, in order to provide a normative grounding for future decisions. Originality/value This study addresses a gap in literature regarding how CAPs actually make resource allocation decisions that affect access to healthcare services.

This meeting of multi-disciplinary researchers (Santa Barbara, CA, February 1999) explored the integration and problems associated with multiple modalities and multiple frames of reference, as represented in spatial language and human decision making. Modality themes included learning environments via maps, navigation, and virtual navigation; tactile, auditory, and visual localization and navigation; and learning environments from spatial descriptions. Reference frames under consideration included relative, intrinsic, and absolute reference frames for describing locations; orientation-free vs. orientation-specific representations; heads-up and north-up maps in navigation systems; mixing gaze, route, and survey perspectives in descriptions; expressing differing modalities or frames through language; and cross-cultural differences in the use of reference frames. This report summarizes the discussions and plenary presentation, and presents a set of research questions for further investigation.

Background

For the last 20 years, health provider organizations have made efforts to align mission, values, and everyday practices to ensure high-quality, high-value, and ethical care. However, little attention has been paid to the organizational values and practices of community-based programs that organize and facilitate access to care for uninsured populations. This study aimed to identify and describe organizational values relevant to resource allocation and policy decisions that affect the services offered to members, using the case of community access programs: county-based programs that provide access to care for the uninsured working poor.

Methods

Comparative and qualitative case study methodology was used, including document review, observations, and key informant interviews, at two geographically diverse programs.

Results

Nine values were identified as relevant to decision making: stewardship, quality care, access to care, service to others, community well-being, member independence, organizational excellence, decency, and fairness. The way these values were deployed in resource allocation decisions that affected services offered to the uninsured are illustrated in one example per site.

Conclusions

This study addresses the previous dearth in the literature regarding an empirical description of organizational values employed in decision making of community organizations. To assess the transferability of the values identified, we compared our empirical results to prior empirical and conceptual work in the United States and internationally and found substantial alignment. Future studies can examine whether the identified organizational values are reflective of those at other health care organizations.

This article proposes an action guide to making decisions regarding the ethical allocation of resources that affect access to healthcare services offered by community-based healthcare organizations. Using the filter of empirical data from a study of decision making in two community-based healthcare organizations, we identify potentially relevant conceptual guidance from a review of frameworks and action guides in the public health, health policy, and organizational ethics literature. We describe the development of this action guide. We used data from a prior empirical study of the values that influence decision making about the allocation of resources in particular types of community-based healthcare organizations. We evaluated, organized, and specified the conceptual guidance we found in 14 frameworks for ethical decision making. The result is an action guide that includes four domains that are relevant to the context of the decision to be made, eight domains that are relevant to the process of the decision to be made, and 15 domains that are relevant to the criteria of the decision to be made. We demonstrate the potential use of this action guide by walking through an illustrative resource allocation decision. The action guide provides community-based healthcare organizations with a conceptually grounded, empirically informed framework for ethical decision making.

The increasing complexity of human subjects research and its oversight has prompted researchers, as well as institutional review boards (IRBs), to have a forum in which to discuss challenging or novel ethical issues not fully addressed by regulations. Research ethics consultation (REC) services provide such a forum. In this article, we rely on the experiences of a national Research Ethics Consultation Collaborative that collected more than 350 research ethics consultations in a repository and published 18 challenging cases with accompanying ethical commentaries to highlight four contexts in which REC can be a valuable resource. REC assists: 1) investigators before and after the regulatory review; 2) investigators, IRBs, and other research administrators facing challenging and novel ethical issues; 3) IRBs and investigators with the increasing challenges of informed consent and risk/benefit analysis; and 4) in providing flexible and collaborative assistance to overcome study hurdles, mediate conflicts within a team, or directly engage with research participants. Institutions that have established, or plan to establish, REC services should work to raise the visibility of their service and engage in open communication with existing clinical ethics consult services as well as the IRB. While the IRB system remains the foundation for the ethical review of research, REC can be a valuable service for investigators, regulators, and research participants aligned with the goal of supporting ethical research.