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3.1 case studies (t)

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3.1 case studies (t)

  1. 1. Case studies in priority setting Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 1
  2. 2. Case study I LHINs in Ontario Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 2
  3. 3. Local Health Integration Networks 14 LHINs established in 2006 in Ontario Commissioners of health care each with own Board of Directors Provider organizations continue to function but are now accountable to LHINs 13 of 14 LHINs signed on to the priority setting project Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 3
  4. 4. LHIN Priority Setting Project LHINs need a strategic, evidence-informed, fair decision- making framework to guide priority setting in practice:• Aligns resources strategically with system goals and community needs• Leads to publicly defensible decisions based on available evidence and community values• Facilitates stakeholder engagement around use of finite resources• Supports public accountability of decision-makers Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 4
  5. 5. Guiding principlesEconomic principles of ‘value for money’ What priorities should be set to optimize health benefits & achieve health system goals given resource constraints?Ethical principles of fair process How should these priorities be set to ensure legitimacy and fairness in the eyes of affected stakeholders?Strategic alignment with LHIN role in Ontario Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 5
  6. 6. Priority Setting Framework 4. Develop decision criteria with stakeholder input. 3. Clarify existing 5. Identify & rank funding resource mix. options. 6. Communicate decisions2. Identify priority setting 1 1 2 2 and rationale.committee. 3 3 4 4 5 5 1 5 2 1 3 1. Determine aim & scope 7. Provide formal decision of decision making. review process. 8. Evaluate & improve. Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 6
  7. 7. Assessment criteria (MCDA)Assessment criteria link LHIN decisions explicitly andsystematically to local and health system strategicdirections, values, and performance goals.Assessment criteria are used to: Assess & rank funding options Explain LHIN decisions to stakeholders Ensure a consistent rationale for LHIN decisionsFour criteria domains were proposed based on theliterature and relevant MoHLTC & LHIN documents Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 7
  8. 8. Decision criteria domainsSTRATEGIC FITAlignment with: IHSP (Integrated Health Service Plan); provider system role (mandate andcapacity)POPULATION HEALTHContribution toward improvements in: Health status, prevalence, health promotion/ preventionSYSTEM VALUESContribution toward fulfilling: Client-focus, partnerships, community engagement, innovation,equity, operational efficiencySYSTEM PERFORMANCEContribution toward improvements in: access, quality, sustainability, integration Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 8
  9. 9. Proposal assessment plan Step 1. Compliance Screen  Legal/regulatory  Contractual Agreements (e.g., AAs) Step 2. Evaluation (15 criteria)  Strategic Fit (2) 1 1  Population Health (3) 2 2  System Values (6) 3 3  System Performance (4) 4 4 5 5 Step 3. Cost-Benefit Analysis Step 4. System Readiness Screen 1 5 2  LHIN capacity 1 3  Interdependency  Risk Health system impact Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 9
  10. 10. LHIN PilotsPilots launched in February 2008Year 2 of LHIN funding ; Some previousexperience to build fromMinistry direction issued in May 2008 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 10
  11. 11. LHIN PilotsNorth West – Urgent Priorities FundChamplain – Urgent Priorities FundCentral West – Aging at Home Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 11
  12. 12. Urgent Priority Funding ’08/09• Funds available: ~$800KIdea sheets Business Funded Success cases proposals rate 91 19 6 7% Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 12
  13. 13. Process overviewGoal was to advance IHSP priorities by targeting ALC/ ERissues in 4 communitiesCriteria: 15 explicitly linked to ALC-ER with relevant metrics Developed by LHIN, reviewed & validated by 23 stakeholders, and approved by BoardProcess: Information Session with Health Service Providers to outline criteria & process Evaluation Committee = 5 LHIN staff + 4 community members EC screened Idea Sheets, identified those for business case development, and evaluated business cases using 4-step tool Applicants notified by letter Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 13
  14. 14. Process EvaluationOn-line Survey of HSPs (n = 110)LHIN Interviews (n = 26)Analysis Local & aggregate analysis Stratified analysis (e.g., sector, outcome) Interdisciplinary analysis using A4R Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 14
  15. 15. Key lessonsMinistry mingling can be a realityAdvisory role of processCommunication and the impact on HSP engagementImportance of leveling the playing field forsubmission developmentAllocating new money versus re-allocating existingmoney and process buy-in Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 15
  16. 16. Case Study II Menno Place Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 16
  17. 17. PlanWhat is Menno Place?Why PBMA at Menno Place?PBMA implementation and resultsThe second year Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 17
  18. 18. Menno PlaceMenno Home and Menno HospitalResidential complex careMenno Home: 196 beds, annual budget about$11.7 million (2007-2008)Menno Hospital:151 beds, annual budgetabout $12.5 millionDaily operations managed by theManagement Team Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 18
  19. 19. Why PBMA?Structural cost problem- Spring 2007Menno Home projected deficit for 08-09 was$355,000Menno Hospital projected deficit for 08-09was $191,000Total projected accumulated deficit at theend of 08-09 almost $1 millionNeed for a “structural” solution Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 19
  20. 20. Implementation- ScopeAcross both the Home and HospitalReallocations from one to the other arepossibleNo pre-set split of cost reduction between thefacilities Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 20
  21. 21. Implementation- Advisory Panel 25 members Union and association are represented Wide but shallow representation Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 21
  22. 22. Implementation- Mission statementTo meet the long-term housing and health needsof our frail and elderly residents by providingquality care and support in a compassionate,Christian environment. Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 22
  23. 23. Implementation- CriteriaDeveloped by Management Team, approved by Advisory panelFour categories: Strategic alignment Technical efficiency Quality of services Management effectiveness Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 23
  24. 24. Criteria- Weights and scoring toolDeveloped by Management Team and approved byAdvisory panelScoring tool went from -3 to +3 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 24
  25. 25. Proposal developmentStaff involvement- with incentivesTwo step process: short form and business case (longform)Requirements : resource releases= 5%No explicit limitations on investment proposals Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 25
  26. 26. Proposal requirementsSeven departments: Resident Care Services Administration People Services Food Services Laundry Housekeeping Maintenance Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 26
  27. 27. Short form proposals111 proposals- 540 staff93 resource releases18 investments80 related to the Home20 related to the Hospital11 related to both Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 27
  28. 28. Short form assessment All proposals were reviewed within one week of submission Feedback on all proposals Proposals were either:- Declined- Returned for rework- Eligible for inclusion in the pool from which the proposals for business case would be selected. Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 28
  29. 29. Business case proposals 12 resource release and 1 resource investment proposals moved to business case How did we get there:- Amalgamation of proposals by theme- Limit on the total number of business case proposals- Assessment on the basis of strategic feasibility from the perspective of the Management Team Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 29
  30. 30. Rating meetingInvestment proposal rating: 94.42Worst resource release proposal rating: -40.84 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 30
  31. 31. Funding recommendations All proposals accepted for implementation Forecasted results: reduction in total costs of about $409,000 for 08/09 Split between Home and Hospital: Home $390,000 Hospital $19,000 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 31
  32. 32. Recommendations implementationProposed by Management Team andapproved by BoardSupport of union and associationInterim budget impact as of October 23,2008: on track for a cost reduction of$399,000 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 32
  33. 33. The next yearBackground: Four year debt elimination plan from the Board with Home and Hospital specific targets Stakeholder pressure: “equitable” distribution of adjustments New Advisory Panel- about one third new members Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 33
  34. 34. Some problems Key symptom of problems: lack of proposals Challenges to proposals development:- lack of enthusiasm for the process- lack of ideas- notions of fairness- no proposal means no PBMA reallocation… Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 34
  35. 35. The next year- Back on track3 points were made with Advisory Panel: PBMA does not determine available resources but works within available resources Within available resources, PBMA gives participants a voice Proposals are the responsibility of Advisory Panel Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 35
  36. 36. Lessons from experience/success factorsShared visionCredible commitment Resources for process (training, ongoing support, time freed up) Incentives to encourage participationLearning/ quality improvement: changes to AdvisoryPanel composition, to templates, to criteria Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 36
  37. 37. Case study IIIVancouver Coastal Health- Community Services Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 37
  38. 38. Community ServicesCommunity services division Services cover a continuum of care – from health promotion and prevention to primary care, secondary care, rehab and palliative Total budget for 09/10: just over $600 million Faced large budget deficit not resolved with ‘usual means’Aim to address the deficit and consider potentialfor re-allocation Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 38
  39. 39. Scope and timeline• Specific programs were targeted by the process (about $250 million of the total program budget)• Programs were excluded for valid reasons: mandated programs, joint programs…• Budget challenge: $4.65 million• Training began Jan. 6, recommendations approved March 23 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 39
  40. 40. Process structureSenior Executive TeamAdvisory PanelWorking Group - included clinical leaders Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 40
  41. 41. ProposalsTwo phases proposal development process: 1) Disinvestments 2) Investments Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 41
  42. 42. Disinvestment proposals55 proposals with a value of approximately$5.4 millionIncluded efficiency gains and service changes(efficiency gains about $650,000)In the end, 44 options recommended with atotal value of $4.9M Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 42
  43. 43. Disinvestment examplesReduce admin support to XX areaDeletion of 0.8 FTE community developer forXX programEliminate weekend youth clinic at XX centreClose Health Contact Centre Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 43
  44. 44. Investment proposals11 proposals with a total value of $1.9 millionPut forward 6 investment options of about$0.5M but working group recommended notevaluating against disinvestment options untilbudget gap cleared Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 44
  45. 45. Project evaluationSuccessful in outlining a plan to meet financialobligationsAll participants said decisions were stronger/ moredefensible then with no processStrong support for process from CFO and wellreceived by senior executive and Board Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 45
  46. 46. Moving forwardDecide on alternative to historical/ political allocationand across the board cutsTraining on principles and process, establish workinggroup, develop criteria and templates Investment and/ or disinvestment proposalssubmitted and assessedRecommendations for changes to resource allocationChanges implementation and process refinement Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 46

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