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Local prioritisation work in health care: assessment of an implementation process
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2007 (English)In: Health Policy, ISSN 0168-8510, Vol. 81, no 2-3, 133-145 p.Article in journal (Refereed) Published
Abstract [en]

Political, horizontal prioritisation requires knowledge on local health care resource use on unit or patient group level. This in turn requires unit level structures (meeting forums) and processes for creation of knowledge and continuous, open decision-making on prioritisation. Ideally, for decisions to be legitimate, such procedures should meet the "Accountability for reasonableness"-criteria of Daniels and Sabin [Daniels N. Accountability for reasonableness. Establishing a fair process for priority setting is easier than agreeing on principles. British Medical Journal 2000;321:1300-1]. A strategy, aiming at shaping such an organisational culture, was developed and set to work within a regional health care organisation, responsible for around 250000 inhabitants. This pilot study regarding topic and methodology assesses the changes of knowledge in open prioritisation as well as structures, processes for and results of such work on unit level in that organisation 1998 through early 2005. Initial interviews and two consecutive surveys were analysed. Results indicate that only early adopters respond to the surveys and among them a growing knowledge in priority setting, acceptance of personal leadership for local priority setting work and recognition of a need for adequate structures and processes. Among respondents, one could note a development: A tentative model expressing different positions towards prioritisation was developed.

Place, publisher, year, edition, pages
2007. Vol. 81, no 2-3, 133-145 p.
Keyword [en]
Open prioritisation; Health care; Implementation
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
URN: urn:nbn:se:umu:diva-36222DOI: 10.1016/j.healthpol.2006.05.007PubMedID: 16824642OAI: diva2:352813
Available from: 2010-09-22 Created: 2010-09-22 Last updated: 2010-10-04Bibliographically approved
In thesis
1. Creating organisational capacity for priority setting in health care: using a bottom-up approach to implement a top-down policy decision
Open this publication in new window or tab >>Creating organisational capacity for priority setting in health care: using a bottom-up approach to implement a top-down policy decision
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In this thesis, priority setting to the form of the Swedish parliamental decision on priority setting, 1997, is considered an innovation for implementation in health care. The features of this innovation are investigated. The practical implications of implementation are identified by investigating the user organisation, ie, Swedish health care organisations and management systems.

Also, a case of a three-stage process for macro-level priority setting that engaged the entire organisation in the Västerbotten County Council (VCC) is presented. This is done against a background of preceding implementation efforts in the VCC.

Four specific research efforts and papers are presented.

In Paper I, priority setting is operationalised into a multi-dimensional resource allocation task. On that basis, with the help of interviews (1998) and surveys (2002 and 2005) primarily of VCC health care managers, the impact of implementation is measured by prioritisation structures, processes and decisions. Survey response rates were low. Results were used as qualitative data, internally compared, and interpreted as: a) responses reflected mainly “early adopters’” opinions; b) priority setting is an ambiguous concept; c) indicating limited overall implementation; d) reinterpretation of the prioritisation task occurred over time among respondents; and, e) this group took increasingly personal responsibility as stakeholders in priority setting.

Paper II reports a case study intervention of explicit, departmental level priority setting with the aim of improving cost-effectiveness in in vitro fertilization resource use and a rationing of services perceived legitimate by all stakeholders. The intervention combined priority setting and structured quality improvement techniques. Results were: a) improved operational efficiency of diagnostic procedures that allowed resources to be reallocated to treatment; and b) patients were prioritized and treatment resources were rationed based on evidence of treatment effect among subgroups. Evaluation showed that the procedure met stated criteria for legitimacy.

In Paper III, a full-format test of the macro level prioritisation process is described and evaluated by participants with the help of surveys after each completed stage. Participants report the need for improvement of elements in the overall process and of procedural specifics. However, overall there was a strong commitment to the initiative and satisfaction with the process and the resulting decisions.

In Paper IV, procedural specifics of the prioritisation process are evaluated. They are also compared to the Program Budgeting and Marginal Analysis (PBMA) framework when used for macro level purposes. Procedures provided intended results such as vertical and horizontal priority setting and a consistent process. However, economic targets were not fully achieved in any of the stages.

Conclusions include that health care management systems are not prepared for priority setting and need profound restructuring and that the prioritisation process described in Papers III and IV was successful because: a) the process satisfied politicians’ directives; b) participants were satisfied with the procedures and perceived the subsequent reallocation decisions as legitimate; and, c) methods resulted in the intended outcome.

Factors suggested as the basis of success include: long-term overall preparations; broad and deep participation; a readiness for change among participants; a stage for horizontal priority setting that added to the quality, feasibility and perceived validity of the knowledge base; a strong process leadership; and politicians determined to protect the process from opportunistic disturbances.

Place, publisher, year, edition, pages
Umeå: Umeå university, 2010. 107 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1368
Health care; priority setting; implementation; management systems
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
urn:nbn:se:umu:diva-36316 (URN)978-91-7459-059-3 (ISBN)
Public defence
2010-10-22, Bergasalen, Byggnad 27, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Available from: 2010-10-01 Created: 2010-09-28 Last updated: 2010-10-04Bibliographically approved

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