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Creating organisational capacity for priority setting in health care: using a bottom-up approach to implement a top-down policy decision
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
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.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1368
Keyword [en]
Health care; priority setting; implementation; management systems
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-36316ISBN: 978-91-7459-059-3 (print)OAI: oai:DiVA.org:umu-36316DiVA: diva2:353707
Public defence
2010-10-22, Bergasalen, Byggnad 27, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2010-10-01 Created: 2010-09-28 Last updated: 2010-10-04Bibliographically approved
List of papers
1. Local prioritisation work in health care: assessment of an implementation process
Open this publication in new window or tab >>Local prioritisation work in health care: assessment of an implementation process
2007 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, 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.

Keyword
Open prioritisation; Health care; Implementation
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-36222 (URN)10.1016/j.healthpol.2006.05.007 (DOI)16824642 (PubMedID)
Available from: 2010-09-22 Created: 2010-09-22 Last updated: 2017-12-12Bibliographically approved
2. Ethically acceptable prioritisation of childless couples and treatment rationing: "accountability for reasonableness"
Open this publication in new window or tab >>Ethically acceptable prioritisation of childless couples and treatment rationing: "accountability for reasonableness"
2008 (English)In: European Journal of Obstetrics, Gynecology, and Reproductive Biology, ISSN 0301-2115, E-ISSN 1872-7654, Vol. 139, no 2, 176-186 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: With in vitro fertilisation serving as a specific case, an intervention was aimed at investigating the potential for applying prioritisation theories and methods in a real-life situation to form an evidence-based proposal that met the standards of the "Accountability for Reasonableness" Model. In turn, this case would serve as a basis for public decision on rationalisation, prioritisation and rationing, whereby given resources are allocated with respect to the ethical template of the Swedish Parliament's decision on priorities in health care. STUDY DESIGN: Management representatives of the overall county council as well as the gynaecologic-obstetric department levels, infertility treatment professionals and a patients' organisation representative worked together to create guidelines building on the ethical principles of human dignity, needs/solidarity and cost-effectiveness, on evidence of treatment effect, epidemiology and economic resources availability. Also quality improvement techniques were used. RESULTS: Due to new guidelines for priority setting, it is expected that more childless couples in the studied health care region will get publicly financed IVF treatment. IVF treatment outcome is expected to be more cost-effective in terms of pregnancies for a given amount of resources. A balance between needs - as defined by the guidelines' criteria - and resources is expected and thus waiting lists are expected to vanish. The patients' organisations representative accepted the guidelines. They were also accepted by all obstetric clinics and formally agreed upon by the political boards of all county councils in the region. CONCLUSION: Use of a deliberative decisions model, structured quality improvement methodology and an accepted model for prioritisation helped create a system for legitimate prioritisation of couples and rationing of treatment regarding a group of patients where differentiation has been considered difficult.

Keyword
In vitro fertilisation, Health priorities, Rationing, Accountability for reasonableness, Structured quality improvement, Total quality management
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-22233 (URN)10.1016/j.ejogrb.2008.02.018 (DOI)18417271 (PubMedID)
Available from: 2009-04-29 Created: 2009-04-29 Last updated: 2017-12-13Bibliographically approved
3. Priority setting in practice: participants opinions on vertical and horizontal priority setting for reallocation
Open this publication in new window or tab >>Priority setting in practice: participants opinions on vertical and horizontal priority setting for reallocation
2010 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 96, no 3, 245-254 p.Article in journal (Refereed) Published
Abstract [en]

In the Västerbotten County Council in Sweden a priority setting process was undertaken to reallocate existing resources for funding of new methods and activities. Resources were created by limiting low priority services. A procedure for priority setting was constructed and fully tested by engaging the entire organisation. The procedure included priority setting within and between departments and political decision making. Participants' views and experiences were collected as a basis for future improvement of the process. Results indicate that participants appreciated the overall approach and methodology and wished to engage in their improvement. Among the improvement proposals is prolongation of the process in order to improve the knowledge base quality. The procedure for identification of new items for funding also needs to be revised. The priority setting process was considered an overall success because it fulfilled its political goals. Factors considered crucial for success are a wish among managers for an economic strategy that addresses existing internal resource allocation; process management characterized by goal orientation and clear leadership; an elaborate communications strategy integrated early in the process and its management; political unity in support of the procedure, and a strong political commitment throughout the process. Generalizability has already been demonstrated by several health care organisations that performed processes founded on this working model.

Keyword
Priority setting; Procedural development; Health care resource reallocation
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-36238 (URN)10.1016/j.healthpol.2010.02.007 (DOI)000280388300009 ()
Available from: 2010-09-23 Created: 2010-09-23 Last updated: 2017-12-12Bibliographically approved
4. Results of a full-format priority setting process: evaluating procedures
Open this publication in new window or tab >>Results of a full-format priority setting process: evaluating procedures
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-36254 (URN)
Available from: 2010-09-23 Created: 2010-09-23 Last updated: 2015-04-29Bibliographically approved

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