Form #6 Form #6 Interrupted Deliberation Facilitator's Guide

Attachment D2:

Interrupted Deliberation Facilitator’s Guide

Interrupted Deliberation Facilitator’s Guide

Objectives:

1. Make it feasible and enjoyable for members of the public to provide input on the ethical issues and social values inherent in the use of evidence from CER in making decisions both at the level of the individual patient and with respect to organizational and/or societal decisions

2. Get meaningful input from members of the public on the overall questions for deliberation and on the meta-questions that specifically arise from the case studies being reviewed

3. Collect data to assess the process and its outcomes

Characteristics:

Hours	6 hours in-person total – 3 hour session, 1 week interruption, 3 hour session Online between sessions
Group size	12 & 24
Experts	2 Experts (on line only between groups)
Breakouts	In groups of 24 will break out into two groups of twelve
Staff	1 facilitator, 1 note taker/ co-facilitator

Group members get standard set of background materials at time of confirmation.

Facilitator Role

1. Lead discussion of entire group and, in larger groups, lead one of the two smaller groups. This involves making sure:

   1. Everyone is participating, calling on those who volunteer but also on those who do not if they are rarely, if ever, volunteering

   2. Everyone is being civil (following ground rules)

   3. Things are moving according to schedule

   4. Everyone feels they understand the process and the objective

2. Follow the script vis-a-vis what is included but not necessarily in the identical language

3. Answer questions about the process, what is covered in the educational materials, or what experts have said

4. Do not answer questions that involve providing additional facts about cases

5. Do not give their own opinions, even when directly asked for them

6. Manage audio recording in small group breakout sessions

Note Taker Role

1. Take notes of group discussions on newsprint on easels. Notes not taken when facilitator is speaking, or if we have a video, while that is being played.

2. On laptop, notes unusual non-verbal activity, especially when it is needed to interpret the transcript

3. Play role of facilitator in small group breakouts in larger Community Deliberation sessions

4. Distribute materials to group members at beginning of the session and as needed throughout

5. Help facilitate the logistics of the session, e.g. manage audio recording

6. Create map of participants in plenary and breakouts

7. Handle informed consents, evaluation surveys and incentives to group members

Session 1 Agenda

Time	Activity
1:00	Session Begins: Staff and participant introductions (10 minutes)
1:10	Welcome; Video welcome, Q&A (5 minutes)
1:15	Review ground rules (5 minutes Q&A)
1:20	Context setting (10 -- 15 minutes including Q&A)
1:35	Review of CER and Slides (15 minutes)
1:50	Presentation of Case One: URI – Variation A (10 minutes)
2:00	Discussion of Case One: URI – Variation A (25 minutes) Note: In large groups, this is where groups break out
2:25	Recap of views (10 minutes)
2:35	Presentation of Case One: URI – Variation C (5 minutes)
2:40	Discussion of Case 1, Variation C (25 minutes) Note: In large groups, this is where groups break out
3:05	Recap of Views (10 minutes)
3:15	Discussion of Web Based Interaction (15 minutes)
3:30	Group ends

*Between sessions, participants can go online to use the discussion forum for up to an hour.

Session 2 Agenda

Time	Activity
1:00	Day 2 Introduction (10 minutes)
1:10	Whole Group Discussion of Case One, including summary of messages to AHRQ (30 minutes)
1:40	Presentation of Case Two, Variation A (10 minutes)
1:50	Discussion of Case Two, Variation A (25 minutes) Note: In large groups, this is where groups break out
2:25	Recap of views (10 minutes)
2:15	Presentation and Discussion of Case Two, Variation C (40 minutes include Q&A) Note: In large groups, this is where groups break out
2:55	Final Whole Group Discussion of Case Two (20 minutes)
3:15	Discussion of response to the deliberative process (15 minutes)
3:30	Facilitator thanks group and ends (5 minutes)

Meeting Set-Up Instructions

Setting Up Meeting – Equipment and Supplies

• Make sure the Agenda and Ground Rules are posted in room

• Chairs

• Table

• Table Name Tents for all participants

• Easel with paper, markers

• Pens, paper for participants

• Laptop, projector

Checklist of materials

Session 1 Materials

• Informed consent forms (2 copies for everyone – one for us; one to be kept by participant)

• Deliberative Experience Knowledge and Attitude Survey (to be completed before group starts)

• 3 audio recorders (if group size 24); 2 audio recorders (if group size 12)

• Video (if created)

• Background slides

• Educational materials (copies for everyone) – put together in a packet, which they are asked to keep

• Poster with overarching question

• Poster with ground rules

• Poster with agenda

• Case Study -- URIs

• Expert bios and statements (copies for everyone)

• Session agenda (copies for everyone) but also on easel

• Instructions for in-between week and Deme (copies for everyone)

Session 2 Materials

• 3 audio recorders (if group size 24); 2 audio recorders (if group size 12)

• Educational materials (copies for everyone) – put together in a packet, which they can keep

• Poster with overarching question

• Poster with ground rules

• Poster with agenda

• Case Study – Hospital Quality

• Expert bios and statements (copies for everyone)

• Deliberative Experience survey (to be taken at the end of the session)

Participant Registration 30 mins

Participant Registration

• Informed Consent

• Meal (can be taken into the room with them)

Participant Over-recruitment

If more than 12 or 24 (depending on group size) participants show, facilitator and note taker determine who to pay and send home.

Session 1 - Welcome and Introductions 10 mins

Objective

• Introduce yourself and any co-facilitators.

• Have participants briefly introduce themselves

Example Facilitator Script:

Thank you for joining us here today. We are all really pleased to have you here and to learn from you. We are here today to learn more about and discuss medical research and health care quality. You've received materials in advance about this session, and we'll be summarizing those materials in a few minutes. But, first, let's do introductions. My name is [insert name], and I will be helping to lead today’s discussion. I am joined by [introduce note-taker(s)], and we’re part of the research team at the American Institutes for Research that is leading this project. In large groups add: (Insert note-taker name) will also help moderate the discussions when we break into smaller groups for part of our time together.)

Please introduce yourselves to the group. Let us know your first name, where you are from and how long you have lived in the area.

Welcome video 5 mins

• Introduce Video

• Hold brief Q&A after video

Example Facilitator Script:

You may also remember that the federal government agency, the Agency for Healthcare Research and Quality, provided the funding for this research because they want to hear what you have to say about health care. To start, we’re going to take a minute to watch a video from the director of the Agency to learn more about why you’re here today.

[After video] Does anyone have any questions about this video?

Review Ground Rules 5 mins

• Present ground rules

• Ask group if there are other ground rules to add

Example Facilitator Script:

Though we'll be presenting some basic background materials, most of the time today will be spent with all of you discussing various issues as a group. Since this is about what all of YOU think, there are some points we'd like you to keep in mind:

• There are no 'right' or 'wrong' answers. All views and perspectives are important and help us learn; this also means that you can change your mind as the discussion proceeds – tell us if you do.

• We are here to learn from YOU. So if we ask certain questions about your views, it is because this is what is most valuable for us to understand.

• We want to hear from everyone. Sometimes we may have to interrupt someone to make sure we keep to our schedule.

• Listen and respond to each other. We are meeting in a group setting because people learn from each other. So don't be shy about questioning your colleagues here. And, of course, maintaining respect for each other – even when we disagree – is important.

• Be open. Sometimes we don't want to say things if we think others will disagree, but here we want you to speak your mind, even if you think that it won't be a popular opinion.

As you can see, we have these summarized on one of the easels in the room, as a reminder.

Context-Setting 15 mins

• Provide a basic understanding of medical research and effectiveness

• Create Participant Value

Example Facilitator Script:

Today we will be discussing how to improve health care in the US. Although medicine has made great strides, there is still a lot we don’t know about the best way to treat, and prevent, a variety of illnesses. In fact, there are so many ways now to treat medical problems that we don’t always know which ones are best – and knowing which existing treatment is most effective is just as important for people’s health as discovering new treatments. So, researchers in organizations across the country are studying existing treatments and services to learn more about them; this research is called Comparative Effectiveness Research, or C-E-R. These can be medications, surgeries, prevention strategies, hospital quality, and others. These studies ask:

• What gets the best results?

• What causes the fewest problems for patients?

• Does one option work better for some patients than others?

• How does the cost of the treatment affect both the individual patient and society as a whole?

• Do some treatments lead to problems or concerns for the community as a whole?

However, these questions do not always lead to clear answers. Often, there may be differing perspectives about what steps to take when the results are not clear-cut or there are trade-offs between them.

Today and over the next week, we will be using specific examples to explore your views about some of these trade-offs. Even though this topic sounds like it is a ‘medical’ issue for doctors, in fact, it is an issue that needs the perspective of people like you. That’s because it raises questions like:

• Should doctors and patients be able to use any treatment they think will work, regardless of what the research says?

• What happens when treatment decisions affect many people, not just the individual patient?

• What is the duty of society to protect patients from possible harm?

Question like these are about what is important to people like you—which is just as important as what is important to the experts. That’s why you are here.

Are there any questions at this point?

Review of CER and Slides 15 mins

• Present background slides

Example Facilitator Script:

I know all you received material about today's session before you arrived here today. I'd like to start with a quick review of the main points that were in the materials to refresh your memory about our topic tonight.

Let’s start with health care quality (SLIDE). The Institute of Medicine, an independent, non-profit organization that provides advice and guidance on health care, says that health care should be safe, effective, timely, patient centered, efficient, and equitable. So when I mentioned earlier that researchers are comparing existing treatments to each other, these are the characteristics they are comparing. Are there any questions or comments about these 6 characteristics of quality?

Now that you know WHAT is being studied, it is also important to know that those studies are being done WELL. Like any scientific work, people want to make sure that certain rules are followed when medical research is conducted, so that the results are ones you can trust. As you can imagine, medical science has very strict rules because people's lives and well-being depend on reliable, high standards of medical research. (SLIDE)

The results of medical research that has been done well are called “medical evidence.” And medical evidence is a big part of good quality healthcare because it tells us what is effective, what is safe, and what is efficient—and for which patients, which brings into play equity or fairness, timeliness, and patient-centeredness.

So what's the problem? What is it that we want YOUR input on? The answer is: even when we have good medical evidence, it is not always followed by doctors and patients—for a variety of reasons. As a result, many Americans do NOT get good quality health care. Over the next several years, a lot of research will be conducted that gives us information we can trust about how well different approaches to addressing health problems work, either for everyone or for a particular group of people.

So here’s an overarching question that really is at the heart of your participation in this Community Deliberation: When we have that information, should society do anything to require or encourage the use of treatments which research shows work better? Or should people and their doctors be able to make their own decisions about which treatments to use, even if it goes against the research results?

We have posted this question on the wall, so you can reflect on it from time to time.

I mentioned earlier that today's discussion is about research on treatments that already exist, called Comparative Effectiveness Research or C-E-R. In CER, researchers compare two or more different approaches to taking care of the same health problem. This comparison may reveal many differences that are important for patient care. One certainly is 'which is more effective.' That’s the main point of CER studies.

Another issue is cost. Often new treatments do not work any better than older ones, but they cost a lot more.

Why does cost matter? The fact that health care costs are rising very fast is pretty common knowledge these days. In fact, health care costs have been increasing much faster than the costs for other things we need. As the graph shows, (SLIDE) health costs have risen to 22 times more than what they were in 1970, compared to 5.5 times more for household goods in general.

But people don't always realize that besides paying more for their own health care coverage such as through health insurance premiums, as taxpayers, we all help pay for others as well. This means we all have a stake in helping to control costs to make sure we are getting the best health care results for the money we spend.

This pie chart shows (SLIDE) what portion of health care costs are paid by government (federal, state, and local, with our taxes), by individuals and families, and by private businesses. So when health care costs go up, that affects all of us and each of us. Costs go up for a lot of different reasons. When thinking about how to use the evidence from medical research, one issue is how to make sure that we get good quality health care without spending a lot more money than we need to.

Are there any questions or comments about this?

Presentation of URI: Case One, Variation A 10 mins

Objectives

• Introduce URI case study, variation A

• Get participants to vote on the statement that best reflects their views

Example Facilitator Script:

Let’s begin the discussion by looking at an example of using medical evidence to improve the quality of health care. We’re going to hand this out, and then I will read it aloud while you each read along:

Case study is handed out; facilitator reads aloud

INSERT FINAL CASE STUDY HERE – URI

What do you think?

Facilitator reads all three statements and then asks: Please check the statement that best reflects your point of view?

_____ If the doctor thinks that an antibiotic will help the child and the parents, then that is more important than what guidelines say.

_____ It is the parents’ decision about getting the antibiotic or not; they care the most for their children and they should decide if they think the benefit of the antibiotic is worth it or not.

_____ If the expert guidelines say that too many antibiotics might harm the child in the long run, then doctors and parents should follow the guidelines.

Let’s get a show of hands for how many people chose each statement. What about the first statement? Okay. Now how about the second statement? And the third statement? Did anyone choose none of these statements? If so, we will want to know why.

Facilitator notes that ideally people will only vote on one statement and makes a note regarding whether or not some participants vote on more than one. Facilitator keeps informal count on a piece of paper.

Discussion of Case One, Variation A 25 mins

Objective

• Lead discussion on values, ethics, and other considerations involved in case study

Facilitator’s note for Group of 24: At this point in the groups with 24 people, break up into two groups: Now we will break out into smaller groups. Each of you has been handed a card with your group number on it – we just mixed you all up at random. (Explain where the groups gather).

Example Facilitator Script:

When groups are set up, then facilitator begins discussion:

Now let’s discuss why you voted the way you did. Feel free to share how sure you felt about your vote. We will take 25 minutes, but we will use the last five minutes to summarize key points. Remember, the group does NOT have to come to agreement. It’s fine if you do, it’s fine if you don’t.

Facilitator then asks people to volunteer to give the reason why they chose as they did, and follows up to elicit similar and dissimilar views, making sure as many people as possible speak. If opinions are not volunteered on these questions, facilitator asks people how they respond to each others’ ideas and what questions they have about them.

As appropriate, facilitator raises the following probes, generally in sequence:

Note taker becomes active here at easel, noting all the key points participants raise and periodically asking if s/he got their comments right.

Progressive probes

• The threat of future harm (the child who no longer responds to antibiotics) seems vague and uncertain. What is the obligation of doctors to protect their patients when the 'threat' seems so distant?

• Is it enough for doctors to warn the parents of the dangers of drug resistance? Or should they refuse to prescribe antibiotics even when the parent insists?

• If the situation was about adults insisting on antibiotics for themselves, is that different than parents insisting on antibiotics for their children?

• If parents’ beliefs and prior experience with URIs in their children reinforces their request for antibiotics, is that a good enough reason for the doctor to disregard the guidelines?

• Parents have other home and work pressures that influence their decisions about medical care. How much should those individual circumstances affect what constitutes 'good care'?

Recap of Views 10 mins

Objective

• Summarize what has been discussed so far

Facilitator’s note: Breakouts reconvene as whole group; each group presents summary of key points OR Single group stops (if possible) and tries to summarize key points.

Example Facilitator Script:

Let’s spend just a few minutes trying to summarize where we have come to. Would anyone like to take a crack at identifying the key points on which people agreed, or the different points of view that people have taken over the course of the discussion, especially toward the end. (Note taker) has been taking some notes on the easels, and putting them around the room for you to use.

That’s great. This is the kind of input that AHRQ is looking for.

Presentation of Case One, Variation C 5 mins

Objectives

• Introduce URI case study, variation C

• Get participants to vote on the statement that best reflects their views

Example Facilitator Script:

Okay, now let’s go a little deeper and see how these decisions made about individual children in individual families play out over the whole community.

Facilitator reads aloud while participants read to themselves

INSERT FINAL CASE STUDY: URI – VARIATION C

Questions? Comments?

Discussion of Case One, Variation C 25 mins

Objective

• Lead discussion on values, ethics, and other considerations involved in case study

Facilitator’s note: At this point in the groups with 24 people, break up into two groups.

Example Facilitator Script:

Now we will go back into our smaller groups, meeting where you were before.

Now that you’ve learned more about over-using antibiotics, which statement best describes your view?

_____ I think it is up to the doctor and family to decide if the antibiotic should be used in each individual case. Families shouldn’t feel responsible for what might or might not happen with future bacteria.

______ I think if everyone really understood this well, more doctors and parents would decide not to take antibiotics unless they knew for sure that they had a bacterial infection.

______ To avoid this problem, there should be stricter rules for when a doctor can order an antibiotic for a patient. We can’t always depend on people doing ‘the right thing’ voluntarily.

Let’s get a show of hands for how many people chose each statement. What about the first statement? Okay. Now how about the second statement? Right. And the third statement? Did anyone choose none of these statements? If so, we will want to know why.

Facilitator notes that ideally people will only vote on one statement and notes if some vote on more than one. Facilitator keeps informal count on a piece of paper.

Now let’s discuss why you voted the way you did. Feel free to share how sure you felt about your vote. We will take 25 minutes, but we will use the last five minutes to summarize key points. Remember, the group does NOT have to come to agreement. It’s fine if you do, it’s fine if you don’t.

Facilitator then asks people to volunteer to give the reason why they chose as they did, and follows up to elicit similar and dissimilar views, making sure as many people as possible speak. If opinions are not volunteered on these questions, facilitator asks people how they respond to each others’ ideas and what questions they have about them.

As appropriate, facilitator raises the following probes, generally in sequence:

Note taker becomes active here at easel, noting all the key points participants raise and periodically asking if s/he got their comments right.

Progressive probes

• In the first part of this discussion, the danger of over-use was described as a possible harm to the individual child. In this second part, the over-use of antibiotics is described as affecting many people, not just the individual. Does this influence your thinking about the 'rules' for using antibiotics? How so?

• The antibiotic guidelines have been successful for many doctors and patients but not all and the threat of antibiotic resistance has not gone away.

• What if anything should the American Academy of Pediatrics do about this?

• Should society take stronger steps to control this problem or assume that not everything can be done perfectly? What steps seem appropriate?

• Should problems like this be left in the hands of doctors and patients because you think we should have a less restrictive society?

• Or, does this issue involve concerns that affect everyone in society which warrants more rules or policies?

• If maintaining the independence of the doctor’s judgment is especially important, under what circumstances would you believe that society should take a stronger role?

Recap of Views 10 mins

Objective

• Summarize what has been discussed so far

Facilitator’s note: Breakouts reconvene as whole group; each group presents summary of key points OR Single group stops (if possible) and tries to summarize key points.

Example Facilitator Script:

Let’s spend just a few minutes trying to summarize where we have come to. Would anyone like to take a crack at identifying the key points on which people agreed, or the different points of view that people have taken over the course of the discussion, especially toward the end. (Note taker) has been taking some notes that you can use.

That’s great. This is the kind of input that AHRQ is looking for. We are all really pleased with the insights you have provided to us and to AHRQ.

Discussion of Web Based Interaction 10 mins

Objective

• Orient participants to the week of online interaction

Example Facilitator Script:

Thanks so much for your input today. We have found it very helpful, and we hope you have found it interesting and useful as well. As you know, we will be getting together again next week, same place, at (insert time).

But in the meantime, we'd like you to keep this discussion going. Just to remind you, the purpose of this ongoing dialogue is to get your input on the key question of our project: Should society do anything to require or encourage the use of treatments that research shows work better? Or should people and their doctors be able to make their own decisions about which treatments to use, even if it goes against the research results? Remember, this is not just about what happens to individuals when these decisions are made, but what happens to society as a whole.

To do this, we have created a special web site. Here are some instructions for signing on to the site and using it. The site is just for this group. The only new people you will meet are two experts who are there to answer your questions, respond to your comments, and in general provide additional perspectives. We are also handing out bios of these two people, and pictures of them. You won’t be seeing them in person, but many people like having some idea of what others look like.

Hand out bios and photos of experts; summary description of web portal; instructions for how to use

Any questions at this point about the experts? Remember, your instruction sheet will let you know what to do if you need help using the site.

The web site will include the following:

• Copies of all the materials we have already given you

• The same bios and photos of the experts we just gave you

• A brief statement from each expert on the issues we have been discussing

• A discussion board on which you can post comments, ask questions, respond to the experts, respond to each other, and if you want, post links to other information you have turned up that you find relevant to our discussion. This is YOUR discussion board.

• I will not participate actively, but I will be “lurking” – I’m just too curious!

The experts will come online at least once a day to check out what people have been saying and add their own responses and comments. Experts may respond to each other as well.

Close to the end of the week, we will put a “poll” on the website, with the same questions we asked you before the last discussion. The polls will be open until midnight on (insert date). We ask you to rank each of the three statements in the poll. You can also add another statement, in your own words, to share your point of view. Votes will be anonymous. You will be able to view the results of the polling as it goes along. You will even be able to change your vote, down to the last minute. We will begin our discussion next week by reviewing the poll as well as the overall discussion on the web. Next week's discussion will be a different situation that you will be discussing – but with some similarities to this one. You'll get the new case study when you arrive next week.

Any questions? Any comments? Have a great week.

Session 2 - Welcome and review of web dialogue 10 mins

Objective

• Welcome everyone back to the session

• Debrief on the online week and web-based dialogue

Example Facilitator Script:

Hello everyone, and welcome back. I would like to go over what happened during the last week. First, how many of you got online? How many of you used the discussion board? How many of you voted?

Would anyone like to say what the experience was like for them overall? What did you think of the experts?

Final Discussion of Case One, Variation C 30 mins

Objectives

• Review poll results from online

• Summarize major discussion points

Example Facilitator Script:

Here are the final results from the poll. They include a list of statements that you folks came up with that you felt were closer to your point of view than any of the three we offered.

Did anyone have a pretty big change of heart or mind? Can you tell us about that, what made you change your mind? Did anyone feel as if they have a clearer sense of their own point of view, even if they didn’t change their mind? What did you learn, if anything, from the discussion with the experts?

Okay, based on that, what do we want to say to AHRQ and others about this case? What are the most important issues/reasons/concerns that this group has surfaced about this topic?

Note taker takes notes on newsprint

Thanks so much. This is great, just what we needed.

Presentation of Case Two: Hospital Quality, Var. A 10 mins

Objective

• Present hospital quality case study

Example Facilitator Script:

Now we will look at another example of using medical evidence to improve the quality of health care. We’re going to hand this out and then I will read it aloud while you each read along:

Case study is handed out; facilitator reads aloud.

INSERT FINAL CASE STUDY HERE – HOSPITAL QUALITY

Are there any questions?

What do you think?

Facilitator reads all three statements and then asks: Which statement best reflects your view?

Given the significant differences in results for patients in these low- and high-volume hospitals, people might have different responses, such as:

• This seems normal – some hospitals get better results than others and that's to be expected.

• The high-volume hospital is the only one I would go to, and I can't imagine why anyone would do anything else.

• Makes me wonder how many people know which hospitals are the better ones.

Does one of these statements reflect your opinion? Has something else occurred to you?

Facilitator asks for show of hands on each statement. Facilitator notes that, ideally, people will only vote on one statement and makes note of whether or not some participants vote on more than one. Facilitator keeps an informal count of the votes, including anyone who did not vote.

Discussion of Case Two, Variation A 25 mins

Objective

• Lead discussion on values, ethics, and other considerations involved in case study

Facilitator’s note: At this point in the groups with 24 people, break up into two groups (same groups as previous session): Now we will break out into smaller groups. Each of you has been handed a card with your group number on it – we just mixed you all up at random. (Explain where the groups gather).

Example Facilitator Script:

When groups are set up, then facilitator begins discussion:

Now, just like last week, let’s discuss why you voted the way you did. Feel free to share how sure you felt about your vote. We will take 25 minutes, FOR SMALL GROUPS ONLY: we will take 5 minutes at the end to summarize so you can share with the other group. Remember, the group does NOT have to come to agreement. It’s fine if you do, it’s fine if you don’t.

Facilitator then asks people to volunteer to give the reason why they chose as they did, and follows up to elicit similar and dissimilar views, making sure as many people as possible speak. If opinions are not volunteered on these questions, facilitator asks people how they respond to each others’ ideas and what questions they have about them. Toward end of discussion, facilitator may ask:

• How is this situation different from the one we talked about earlier? How did that affect your vote, if at all?

• Think back to the discussions you had with the experts on the web. What do you think (Expert One) would have had to say about these questions? What about (Expert Two)?

As appropriate, facilitator raises the following probes, generally in sequence:

Progressive probes

• Should doctors be obligated to tell their patients about these different rates? If the doctor practices at the low-volume hospital, is s/he obligated to tell patients that other hospitals gets better results?

• Should physicians do more than simply inform their patients? Should they encourage patients to get care where it will be more effective? Do they have an ethical obligation to do so?

• What reasons can you think of that would cause individuals to choose a hospital that didn’t have the “best” results?

• What is the patient's responsibility to seek out information about the results that different hospitals get?

• Should patients be given incentives, like lower copayments, to make 'good' decisions about where they get their care? Should negative incentives be used?

• Should we require patients to go to the hospital that is going to get the best results?

• If government knows that some hospital care is poorer quality, should it have standards that hospitals must reach in order to provide the service?

Recap of Views 10 mins

Objective

• Summarize what has been discussed so far

Facilitator’s note: Breakouts reconvene as whole group; each group presents summary of key points OR Single group stops (if possible) and tries to summarize key points.

Example Facilitator Script:

Let’s spend just a few minutes trying to summarize where we have come to. Would anyone like to take a crack at identifying the key points on which people agreed, or the different points of view that people have taken over the course of the discussion, especially toward the end. (Note taker) has been taking some notes that you can use.

That’s great. This is the so interesting. Let’s move on.

Presentation and Discussion of Case One, Var. C 40 mins

Objectives:

• Present hospital volume case study, variation C

• Get participants to vote on the statement that best reflects their views

Example facilitator script:

As we did with the first case, let’s see how this situation plays out in the community as a whole. In groups of 24: We are going to break into our small groups again now. (Note this is earlier than in the previous cases, primarily because the “What do you think” question goes right into reasons for the views people hold.

Case study is handed out; facilitator reads aloud.

INSERT FINAL CASE STUDY HERE – HOSPITAL QUALITY

Any questions?

What do you think?

Suppose all of you are on the Springview town council that has to make the decisions on behalf of all the county employees and their families.

Which heath plan would you pick and why?

Who would vote for the plan that gives access to the local hospital for almost everything?

Who would go for the plan that gives access to the “high volume” hospital some distance away for almost everything?

Let’s discuss the reasons you chose the health plan you chose and how sure you felt about your vote.

We will have until (insert time) for this discussion, but as before, we will have time later to recap. Remember, you do NOT have to reach agreement across the group. It’s fine if you do, it’s fine if you don’t.

Facilitator then asks people to volunteer to give the reason why they chose as they did, and follows up to elicit similar and dissimilar views, making sure as many people as possible speak.

As appropriate, facilitator raises the following probes, generally in sequence:

Initial Progressive probes:

• As a resident of Springview yourself, what to you is the highest priority? What do you think is the highest priority for the community?

• How would you describe the conflict that Springview faces? What are the main problems that are central to this town council decision?

• Are there additional facts that would help you make this decision?

• Are there other considerations that haven’t been taken into account?

• Who is responsible for deciding which type of care people have access to? Is it the right place for employers/insurance companies to decide? Or, is this role more appropriate for the government?

• How does medical evidence play a role here? How should it play a role? Are there other concerns/considerations that are important than evidence?

Additional probes:

When you first saw the over-all differences between low and high volume hospitals, these research findings didn't indicate how many people were actually affected.

Imagine that the town council decided to research the numbers of people affected by going to Springview Community Hospital. They learned that when the total impact on local patients added up, last year 4 residents of Springview (including one child) died that wouldn't have if they had received their care at the high-volume hospital. Several other patients did not recover as quickly or had some long-term problems because of less skilled care.

• Does this figure make your job easier or more difficult?

• Where should society put the brakes on allowing individuals to make decisions that will affect/harm society or themselves?

• Where is the greater harm: reducing access to local medical care services or increasing the risks for patients?

Final Whole Group Discussion of Case Two 20 mins

Objective

• Summarize major discussion points regarding case study

In larger groups, two groups reconvene as a whole.

Example Facilitator Script:

Now that we are all back together, let’s ask again: Which health plan would you choose? How many people changed their mind?

Facilitator asks for show of hands for each plan; then asks reasons people changed their mind, or didn’t.

Let’s see if we can come to some general conclusions now. Remember, we do NOT have to reach agreement. We are interested in how and why people’s opinions vary based on their values and their way of thinking about problems.

Supposing using evidence about what works best leads to economic problems for a particular group, community or institution?

How do we balance providing the best possible care for particular individuals with the consequences for society as a whole?

What evidence should get priority when there are other considerations for people?

What other considerations do you think may be as important as or more important than the evidence? What are not?

What do we want to say about this case as a whole to AHRQ? To anyone else?

Discussion of response to deliberative process 10 mins

Objective:

• Explore how the participants felt about the deliberative process and discussion

Example Facilitator Script:

Having gone through this twice, how does this experience make you feel about bringing members of the public together to provide input on important health care issues?

How could we have done this better? What has worked the best for you?

Thank group and end 5 mins

Thank you so much for giving all your time, your energy, and your ideas to this discussion. We will be summarizing the input we have gotten from all the group discussions and providing them to AHRQ. We hope you have found this as worthwhile as we have.

Safe travels!