3.1 case studies (t)

Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 1

Case studies in priority setting


Case study I

LHINs in Ontario


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


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


Guiding principles

•Economic 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


Priority Setting Framework

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1. Determine aim & scopeof decision making.

4. Develop decision criteriawith stakeholder input.

3. Clarify existing resource mix.

5. Identify & rank funding options.

7. Provide formal decision review process.

8. Evaluate & improve.

6. Communicate decisionsand rationale. 2. Identify priority setting

committee.


Assessment criteria (MCDA)• Assessment criteria link LHIN decisions explicitly and

systematically to local and health system strategic directions, values, and performance goals.

• Assessment criteria are used to:

• Assess & rank funding options

• Explain LHIN decisions to stakeholders

• Ensure a consistent rationale for LHIN decisions

• Four criteria domains were proposed based on the literature and relevant MoHLTC & LHIN documents


Decision criteria domains

STRATEGIC FITAlignment with: IHSP (Integrated Health Service Plan); provider system role (mandate and capacity)

POPULATION HEALTHContribution toward improvements in: Health status, prevalence, health promotion/ prevention

SYSTEM VALUESContribution toward fulfilling: Client-focus, partnerships, community engagement, innovation, equity, operational efficiency

SYSTEM PERFORMANCEContribution toward improvements in: access, quality, sustainability, integration


Proposal assessment planStep 1. Compliance Screen

Legal/regulatory Contractual Agreements (e.g., AAs)

Step 2. Evaluation (15 criteria) Strategic Fit (2) Population Health (3) System Values (6) System Performance (4)

Step 3. Cost-Benefit Analysis

Step 4. System Readiness Screen LHIN capacity Interdependency Risk Health system impact

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LHIN Pilots•Pilots launched in February 2008

•Year 2 of LHIN funding ; Some previous experience to build from

•Ministry direction issued in May 2008


LHIN Pilots

• North West – Urgent Priorities Fund

• Champlain – Urgent Priorities Fund

• Central West – Aging at Home


Urgent Priority Funding ’08/09

Idea sheets Business cases

Funded proposals

Success rate

91 19 6 7%

• Funds available: ~$800K


Process overview• Goal was to advance IHSP priorities by targeting ALC/ ER

issues in 4 communities

• Criteria: 15 explicitly linked to ALC-ER with relevant metrics

• Developed by LHIN, reviewed & validated by 23 stakeholders, and approved by Board

• Process:

• 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


Process Evaluation

• On-line Survey of HSPs (n = 110)

• LHIN Interviews (n = 26)

• Analysis

• Local & aggregate analysis

• Stratified analysis (e.g., sector, outcome)

• Interdisciplinary analysis using A4R


Key lessons•Ministry mingling can be a reality

•Advisory role of process

•Communication and the impact on HSP engagement

• Importance of leveling the playing field for submission development

•Allocating new money versus re-allocating existing money and process buy-in


Case Study II

Menno Place


Plan

•What is Menno Place?

•Why PBMA at Menno Place?

•PBMA implementation and results

•The second year


Menno Place•Menno Home and Menno Hospital

•Residential complex care

•Menno Home: 196 beds, annual budget about $11.7 million (2007-2008)

•Menno Hospital:151 beds, annual budget about $12.5 million

•Daily operations managed by the Management Team


Why PBMA?•Structural cost problem- Spring 2007

•Menno Home projected deficit for 08-09 was $355,000

•Menno Hospital projected deficit for 08-09 was $191,000

•Total projected accumulated deficit at the end of 08-09 almost $1 million

•Need for a “structural” solution


Implementation- Scope

•Across both the Home and Hospital

•Reallocations from one to the other are possible

•No pre-set split of cost reduction between the facilities


Implementation- Advisory Panel

•25 members

•Union and association are represented

•Wide but shallow representation


Implementation- Mission statement

To meet the long-term housing and health needs of our frail and elderly residents by providing quality care and support in a compassionate, Christian environment.


Implementation- CriteriaDeveloped by Management Team, approved by Advisory

panel

Four categories:

• Strategic alignment

• Technical efficiency

• Quality of services

• Management effectiveness


Criteria- Weights and scoring tool

• Developed by Management Team and approved by Advisory panel

• Scoring tool went from -3 to +3


Proposal development

• Staff involvement- with incentives

• Two step process: short form and business case (long form)

• Requirements : resource releases= 5%

• No explicit limitations on investment proposals


Proposal requirementsSeven departments:

• Resident Care Services

• Administration

• People Services

• Food Services

• Laundry

• Housekeeping

• Maintenance


Short form proposals• 111 proposals- 540 staff

• 93 resource releases

• 18 investments

• 80 related to the Home

• 20 related to the Hospital

• 11 related to both


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.


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


Rating meeting

Investment proposal rating: 94.42

Worst resource release proposal rating: -40.84


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


Recommendations implementation

•Proposed by Management Team and approved by Board

•Support of union and association

• Interim budget impact as of October 23, 2008: on track for a cost reduction of $399,000


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


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…


The next year- Back on track

3 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


Lessons from experience/success factors

•Shared vision

•Credible commitment

•Resources for process (training, ongoing support, time freed up)

• Incentives to encourage participation

•Learning/ quality improvement: changes to Advisory Panel composition, to templates, to criteria


Case study III

Vancouver Coastal Health- Community Services


Community Services•Community 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 potential for re-allocation


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


Process structure

•Senior Executive Team

•Advisory Panel

•Working Group - included clinical leaders


Proposals

Two phases proposal development process:

1) Disinvestments

2) Investments


Disinvestment proposals

•55 proposals with a value of approximately $5.4 million

• Included efficiency gains and service changes (efficiency gains about $650,000)

• In the end, 44 options recommended with a total value of $4.9M


Disinvestment examples

•Reduce admin support to XX area

•Deletion of 0.8 FTE community developer for XX program

•Eliminate weekend youth clinic at XX centre

•Close Health Contact Centre


Investment proposals

•11 proposals with a total value of $1.9 million

•Put forward 6 investment options of about $0.5M but working group recommended not evaluating against disinvestment options until budget gap cleared


Project evaluation

• Successful in outlining a plan to meet financial obligations

• All participants said decisions were stronger/ more defensible then with no process

• Strong support for process from CFO and well received by senior executive and Board


Moving forward• Decide on alternative to historical/ political allocation

and across the board cuts

• Training on principles and process, establish working group, develop criteria and templates

• Investment and/ or disinvestment proposals submitted and assessed

• Recommendations for changes to resource allocation

• Changes implementation and process refinement

3.1 case studies (t)

Health & Medicine

priority setting framework

resource constraints

urgent priority funding

lhin role

health system goals

lhin staff

lhin capacity

lhin pilotspilots