Priority Setting Practices Research Articles

Determining and broadening the definition of impact from implementing a rational priority setting approach in a healthcare organization

Techniques to manage scarce healthcare resources continue to evolve in response to changing, growing and competing demands. Yet there is no standard definition in the priority setting literature of what might constitute the desired impact or success of resource management activities.In this 2006–09 study, using action research methodology, we determined the impact of implementing a formal priority setting model, Program Budgeting and Marginal Analysis (PBMA), in a Canadian health authority. Qualitative data were collected through post year-1 (n = 12) and year-2 (n = 9) participant interviews, meeting observation and document review. Interviews were analyzed using a constant comparison technique to identify major themes.Impact can be defined as effects at three levels: system, group, and individual. System-level impact can be seen in the actual selection of priorities and resource re-allocation. In this case, participants prioritized a list of $760,000 worth of investment proposals and $38,000 of disinvestment proposals; however, there was no clear evidence as to whether financial resources were reallocated as a result. Group and individual impacts, less frequently reported in the literature, included changes in priority setting knowledge, attitudes and practice. PBMA impacts at these three levels were found to be interrelated.This work argues in favor of attempts to expand the definition of priority setting success by including both desired system-level outcomes like resource re-allocation and individual or group level impacts like changes to priority setting knowledge, attitudes and practice. These latter impacts are worth pursuing as they appear to be intrinsic to successful system-wide priority setting. A broader definition of PBMA impact may also suggest conceptualizing PBMA as both a priority setting approach and as a tool to develop individual and group priority setting knowledge and practice. These results should be of interest to researchers and decision makers using or considering a formal priority setting approach to manage scarce healthcare resources.

Changing priority setting practice: The role of implementation in practice change

BackgroundProgramme budgeting and marginal analysis (PBMA) is a priority setting approach that assists decision makers in choosing among resource demands. This paper describes and evaluates the process of implementing PBMA in a Canadian regional health authority, and draws out key lessons learned from this experience. MethodsQualitative data were collected through semi-structured participant interviews (twelve post year-1; nine post year-2), meeting attendance, and document review. Interview transcripts were analyzed using a constant comparison technique. Other data were analyzed to evaluate PBMA implementation. ResultsDesire for more clarity and for PBMA adaptations emerged as overarching themes. Participants desired greater clarity of their roles and how PBMA should be used to achieve PBMA's potential benefits. They argued that each PBMA stage should be useful independent of the others so that implementation could be adapted. To help improve clarity and ensure that resources were available to support PBMA, participants requested an organizational readiness and capacity assessment. ConclusionWe suggest tactics by which PBMA may be more closely aligned with real-world priority setting practice. Our results also contribute to the literature on PBMA use in various healthcare settings. Highlighting implementation issues and potential responses to these should be of interest to decision makers implementing PBMA and other evidence-informed practices.

Setting healthcare priorities in hospitals: a review of empirical studies.

Priority setting research has focused on the macro (national) and micro (bedside) level, leaving the meso (institutional, hospital) level relatively neglected. This is surprising given the key role that hospitals play in the delivery of healthcare services and the large proportion of health systems resources that they absorb. To explore the factors that impact upon priority setting at the hospital level, we conducted a thematic review of empirical studies. A systematic search of PubMed, EBSCOHOST, Econlit databases and Google scholar was supplemented by a search of key websites and a manual search of relevant papers’ reference lists. A total of 24 papers were identified from developed and developing countries. We applied a policy analysis framework to examine and synthesize the findings of the selected papers. Findings suggest that priority setting practice in hospitals was influenced by (1) contextual factors such as decision space, resource availability, financing arrangements, availability and use of information, organizational culture and leadership, (2) priority setting processes that depend on the type of priority setting activity, (3) content factors such as priority setting criteria and (4) actors, their interests and power relations. We observe that there is need for studies to examine these issues and the interplay between them in greater depth and propose a conceptual framework that might be useful in examining priority setting practices in hospitals.

Формирование приоритетов инновационной политики и оценка их реализации: европейский опыт и уроки для Украины

Румпф Гудрун - руководитель проекта, Департамент информационно-коммуникационных и консалтинговых услуг, INTRASOFT International (Люксембург). E-mail: Rumpf.Gudrun@gmail.comАдрес: 2b rue Nicolas Bov, L - 1253 LuxembourgОдна из важнейших составляющих научно-технической и инновационной политики - формирование приоритетов поддержки перспективных технологий и областей. При наличии ряда общих принципов процедуры отбора приоритетов и их конечные эффекты характеризуются значительным межстрановым разнообразием, которое обусловлено различиями национальных культур, историческими предпосылками, спецификой институциональных структур. По этой причине нередко возникает разрыв между декларируемыми целями политики и ее фактической реализацией. Подобная ситуация сложилась в ряде развивающихся государств, в частности, на Украине. Страна обладает развитой системой законодательства в сфере науки, технологий и инноваций, а также солидной методологической базой для выбора приоритетов. Вместе с тем заявленные цели не подкреплены соответствующими механизмами реализации, включая рамочные условия, программы, процедуры их мониторинга и оценки.В статье анализируется опыт ряда ведущих европейских стран; приводятся рекомендации по совершенствованию процесса установления приоритетов и, как следствие, инновационной политики в целом.Автор приходит к выводу, что опора на излишне узкий перечень тематических приоритетов в условиях быстрых темпов технологических и социальных изменений рискует завести в тупик. С другой стороны, чрезмерно широкий спектр приоритетов ведет к потере фокуса политики. Оптимальный баланс может быть достигнут, если государство сфокусируется на постановке общих задач и ориентиров развития и обеспечении необходимых рамочных условий и инфраструктуры для развития инноваций, способствуя действующим «снизу» рыночным драйверам в выборе тематических приоритетов. При этом за определение приоритетов и их имплементацию должны отвечать организации или ведомства, обладающие необходимыми ресурсами и компетенциями. Тем самым обеспечиваются вертикальная и горизонтальная координация, а также широкое участие заинтересованных сторон в процессе подготовки и реализации национальной инновационной стратегии.

Current Evaluation Practices Involving Resource Allocation Processes in Canadian Healthcare Organizations: A Survey of Senior Managers

Abstract: Resource allocation is a key function of senior leadership teams within healthcare organizations. Academic support of this function has traditionally focused on constructing tools to make decisions more formalized, and much less attention has been paid to understanding resource allocation as a management process. In particular, evaluation has been a missing aspect. The authors conducted a pan-Canadian survey of senior managers within the healthcare system. This survey included questions related to formal evaluation of their resource allocation processes and outcomes. We use these data to shed some light upon the state of priority-setting practice in Canada at the present time.

Using evaluation theory in priority setting and resource allocation

Public sector interest in methods for priority setting and program or policy evaluation has grown considerably over the last several decades, given increased expectations for accountable and efficient use of resources and emphasis on evidence-based decision making as a component of good management practice. While there has been some occasional effort to conduct evaluation of priority setting projects, the literatures around priority setting and evaluation have largely evolved separately. In this paper, the aim is to bring them together. The contention is that evaluation theory is a means by which evaluators reflect upon what it is they are doing when they do evaluation work. Theories help to organize thinking, sort out relevant from irrelevant information, provide transparent grounds for particular implementation choices, and can help resolve problematic issues which may arise in the conduct of an evaluation project. A detailed review of three major branches of evaluation theory--methods, utilization, and valuing--identifies how such theories can guide the development of efforts to evaluate priority setting and resource allocation initiatives. Evaluation theories differ in terms of their guiding question, anticipated setting or context, evaluation foci, perspective from which benefits are calculated, and typical methods endorsed. Choosing a particular theoretical approach will structure the way in which any priority setting process is evaluated. The paper suggests that explicitly considering evaluation theory makes key aspects of the evaluation process more visible to all stakeholders, and can assist in the design of effective evaluation of priority setting processes; this should iteratively serve to improve the understanding of priority setting practices themselves.

Priority-Setting Institutions in Health: Recommendations from a Center for Global Development Working Group

The rationing problem is common to all health systems—the challenge of managing finite resources to address unlimited demand for services. In most low- and middle-income countries, rationing occurs as an ad hoc, haphazard series of nontransparent choices that reflect the competing interests of governments, donors, and other stakeholders. Yet in a growing number of countries, more explicit processes, with strengths and limitations, are under development that merit better support. Against this background, the purpose of the Center for Global Development Working Group, which is to examine how priorities are set currently, and to propose institutional arrangements that promote country ownership and improve health outcomes by more systematically managing this complex process of politics and economics, is discussed. Current global and national priority-setting practices in low- and middle-income countries, the potential for strengthened national institutions, and increased global support are reviewed. Recommendations for action are provided.

The Development and Implementation of a User-Friendly Priority Setting Tool for HIV Care and Treatment Services in New York City

The Ryan White Human Immunodeficiency Virus (HIV) Program is the largest federal program designed to provide medical and social support services for HIV infected persons who are uninsured or underinsured. In 2008, the Ryan White budget was $2.2 billion, of which over $100 million went to the New York City (NYC) eligible metropolitan area (EMA), which receives the largest Ryan White allocation targeted to any EMA. The NYC Department of Health and Mental Hygiene (DOHMH) is the grantee for the EMA. To implement HIV care and treatment programs funded by this grant, the DOHMH works closely with the NYC Ryan White Planning Council, a local community planning body that assesses needs, plans for service delivery and sets priorities for funds. This article describes priority setting principles, practices, findings and lessons learned. It also outlines how the legislatively mandated community planning body has developed and implemented a user-friendly priority setting process and tool.

Racionamento dos cuidados de saúde: problemática inerente

Limited resources in the health sector force a process of choice between alternative health care programs and services and patients or groups of patients who will receive care. In the absence of a price mechanism, the priority-setting process serves to allocate scarce resources among competing uses, and is thus a form of rationing. Traditionally, implicit approaches have dominated the health sector's decision-making, mostly by physicians. However, in the face of increasing budget constraints and rising patient expectations, more explicit and socially acceptable priority-setting practices are needed. Internationally, the development of explicit prioritization has proven difficult and controversial.

Priority setting in the provincial health services authority: survey of key decision makers

BackgroundIn recent years, decision makers in Canada and elsewhere have expressed a desire for more explicit, evidence-based approaches to priority setting. To achieve this aim within health care organizations, knowledge of both the organizational context and stakeholder attitudes towards priority setting are required. The current work adds to a limited yet growing body of international literature describing priority setting practices in health organizations.MethodsA qualitative study was conducted using in-depth, face-to-face interviews with 25 key decision makers of the Provincial Health Services Authority (PHSA) of British Columbia. Major themes and sub-themes were identified through content analysis.ResultsPriorities were described by decision makers as being set in an ad hoc manner, with resources generally allocated along historical lines. Participants identified the Strategic Plan and a strong research base as strengths of the organization. The main areas for improvement were a desire to have a more transparent process for priority setting, a need to develop a culture which supports explicit priority setting, and a focus on fairness in decision making. Barriers to an explicit allocation process included the challenge of providing specialized services for disparate patient groups, and a lack of formal training in priority setting amongst decision makers.ConclusionThis study identified factors important to understanding organizational context and informed next steps for explicit priority setting for a provincial health authority. While the PHSA is unique in its organizational structure in Canada, lessons about priority setting should be transferable to other contexts.

A Strategy to Improve Priority Setting in Developing Countries

Because the demand for health services outstrips the available resources, priority setting is one of the most difficult issues faced by health policy makers, particularly those in developing countries. Priority setting in developing countries is fraught with uncertainty due to lack of credible information, weak priority setting institutions, and unclear priority setting processes. Efforts to improve priority setting in these contexts have focused on providing information and tools. In this paper we argue that priority setting is a value laden and political process, and although important, the available information and tools are not sufficient to address the priority setting challenges in developing countries. Additional complementary efforts are required. Hence, a strategy to improve priority setting in developing countries should also include: (i) capturing current priority setting practices, (ii) improving the legitimacy and capacity of institutions that set priorities, and (iii) developing fair priority setting processes.

PRIORITY SETTING IN THE PROVINCIAL HEALTH SERVICES AUTHORITY: SURVEY OF KEY DECISION MAKERS.

Introduction In recent years, decision makers in Canada and elsewhere have expressed a desire for more explicit, evidence-based approaches to priority setting. To achieve this aim within health care organizations, knowledge of both the organizational context and stakeholder attitudes toward priority setting is required. The current work adds to a growing body of international literature describing priority setting practices in health organizations. Methods A qualitative study was conducted using in-depth, face-to-face interviews with 25 key decision makers of the Provincial Health Services Authority (PHSA) of British Columbia. Major themes and subthemes were identified and reported on through content analysis. Results Priorities were described by decision makers as being set in an ad hoc manner, with resources generally allocated along historical lines. Participants identified the strategic plan and a strong research base as strengths of the organization. The main areas for improvement were a desire to have a more transparent process for priority setting, a need to develop a culture that supports explicit priority setting, and a focus on fairness in decision making. Barriers to an explicit allocation process included the challenge of providing specialized services for disparate patient groups and a lack of formal training in priority setting among decision makers. Conclusion This study identified factors important to understanding organizational context and informed next steps for explicit priority setting for a provincial health authority. Although the PHSA is unique in its organizational structure in Canada, lessons about priority setting should be transferable to other contexts.

Priority setting and cardiac surgery: A qualitative case study

Purpose The purpose of this study is to describe priority setting in cardiac surgery and evaluate it using an ethical framework, “accountability for reasonableness”. Introduction: Cardiac surgery is an expensive part of hospital budgets. Priority setting decisions are made daily regarding ever increasing volumes of patients. While much attention has been paid to the management of cardiac surgery waiting lists, little empirical research exists into the way actual decision makers deliberate upon and resolve priority setting decisions on a daily basis. A key goal of priority setting, in cardiac surgical areas as well as others, is fairness. “Accountability for reasonableness” is a leading ethical framework for fair priority setting, and can be used to identify opportunities for improvement (i.e. make it fairer) and highlight good practices. Methods A case study was conducted to examine the process of priority setting processes at three University of Toronto affiliated cardiac surgery centres. Relevant documents were examined, weekly triage rounds were observed for 27 months, and interviews were carried out with 23 key participants including cardiac surgeons, cardiologists, and triage nurses. In data analysis, the conditions of “accountability for reasonableness” (relevance, publicity, appeals and enforcement) were used as an analytic lens. Results Relevance: While decisions may appear to be based strictly upon clinical criteria (e.g. coronary anatomy); non-clinical criteria also have an impact upon decision-making (e.g. patients’ lifestyle choices, type of surgical practice and departmental constraints on resource use). Participants stated that these factors influence their decision-making and can result in unfair and inconsistent decisions. Publicity: Non-clinical reasons are not publicly accessible, nor are they clearly acknowledged in discussions between cardiac clinicians. Appeals: There are mechanisms for challenging decisions however without access to the non-clinical reasons, this can be problematic. Enforcement: Participants cite little departmental or institutional support to engage in fairer priority setting. Conclusions To our knowledge, this is the first study to describe actual priority setting practices for cardiac surgery practices and evaluate them using an ethical framework, in this case, “accountability for reasonableness”. Priority setting decision making in cardiac surgery has been described and evaluated with lessons learned include specific findings regarding the contextual and dynamic nature of decision making in cardiac surgery. The approach of combining a descriptive case study with the ethical framework of “accountability for reasonableness” is a useful tool for identifying good practices and highlighting areas for improvement. The good practices (including surgeons strongly facilitating patients seeking second opinions and approaching patients from a holistic perspective in consideration for surgery) and areas for improvement (including lack of transparency and lack of institutional support for “fair” decision making) that we have identified in this case study can be used to reflect upon the present tool used in priority setting and improve the fairness and legitimacy of priority setting decision making in cardiac surgery.

Application of economic principles in healthcare priority setting

In healthcare, resources are often insufficient to meet all claims on them. In this respect, resources are considered scarce and have to be managed by prioritizing between competing claims. Economics as a discipline explicitly addresses this reality by acknowledging resource scarcity. However, the extent to which economics actually influences such prioritizing decisions in healthcare is unclear. The purpose of this paper is to review the use of economics in priority setting decision making. We outline the key principles of economics as they apply to priority setting and review the methods reported in the literature with respect to these. We find that these methods, even economic methods (e.g., those typically used in conducting economic evaluations such as cost–effectiveness analyses) do not tend to explicitly incorporate economic principles. We argue therefore that these methods, when applied to the context of priority setting, are not sufficient and that what is required is a broader framework that can incorporate the output from economic methods yet also be pragmatically applicable. We then go on to present an alternative approach – namely program budgeting and marginal analysis. Finally, we put forward our case for using program budgeting and marginal analysis in priority setting practice and set out some future research challenges.

Leadership and priority setting: The perspective of hospital CEOs

The role of leadership in health care priority setting remains largely unexplored. While the management leadership literature has grown rapidly, the growing literature on priority setting in health care has looked in other directions to improve priority setting practices—to health economics and ethical approaches. Consequently, potential for improvement in hospital priority setting practices may be overlooked. A qualitative study involving interviews with 46 Ontario hospital CEOs was done to describe the role of leadership in priority setting through the perspective of hospital leaders. For the first time, we report a framework of leadership domains including vision, alignment, relationships, values and process to facilitate priority setting practices in health services’ organizations. We believe this fledgling framework forms the basis for the sharing of good leadership practices for health reform. It also provides a leadership guide for decision makers to improve the quality of their leadership, and in so doing, we believe, the fairness of their priority setting.

What do hospital decision-makers in Ontario, Canada, have to say about the fairness of priority setting in their institutions?

BackgroundPriority setting, also known as rationing or resource allocation, occurs at all levels of every health care system. Daniels and Sabin have proposed a framework for priority setting in health care institutions called 'accountability for reasonableness', which links priority setting to theories of democratic deliberation. Fairness is a key goal of priority setting. According to 'accountability for reasonableness', health care institutions engaged in priority setting have a claim to fairness if they satisfy four conditions of relevance, publicity, appeals/revision, and enforcement. This is the first study which has surveyed the views of hospital decision makers throughout an entire health system about the fairness of priority setting in their institutions. The purpose of this study is to elicit hospital decision-makers' self-report of the fairness of priority setting in their hospitals using an explicit conceptual framework, 'accountability for reasonableness'.Methods160 Ontario hospital Chief Executive Officers, or their designates, were asked to complete a survey questionnaire concerning priority setting in their publicly funded institutions. Eight-six Ontario hospitals completed this survey, for a response rate of 54%. Six close-ended rating scale questions (e.g. Overall, how fair is priority setting at your hospital?), and 3 open-ended questions (e.g. What do you see as the goal(s) of priority setting in your hospital?) were used.ResultsOverall, 60.7% of respondents indicated their hospitals' priority setting was fair. With respect to the 'accountability for reasonableness' conditions, respondents indicated their hospitals performed best for the relevance (75.0%) condition, followed by appeals/revision (56.6%), publicity (56.0%), and enforcement (39.5%).ConclusionsFor the first time hospital Chief Executive Officers within an entire health system were surveyed about the fairness of priority setting practices in their institutions using the conceptual framework 'accountability for reasonableness'. Although many hospital CEOs felt that their priority setting was fair, ample room for improvement was noted, especially for the enforcement condition.

Doctors' professional values: results from a cohort study of United Kingdom medical graduates.

To examine young doctors' views on a number of professional issues including professional regulation, multidisciplinary teamwork, priority setting, clinical autonomy and private practice. Postal survey of 545 doctors who graduated from United Kingdom medical schools in 1995. Questionnaires were returned by 95% of the cohort (515/545). On issues of professional regulation, teamwork and clinical autonomy, the majority of doctors held views consistent with current General Medical Council guidance. The majority supported the right of doctors working in the NHS to engage in private practice. Most respondents thought that public expectations of doctors, medicine and the NHS were too high, and that some form of rationing was inevitable. On many issues there was considerable variation in attitudes on the basis of sex and intended branch of medicine. The results highlight the heterogeneity of the profession and the influence of specialty and gender on professional values. Doctors' attitudes had also been shaped by broader social changes, especially debates surrounding regulation of the profession, rising public expectations and the need for rationing of NHS care.