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Priority setting in the provincial health services authority: survey of key decision makers Teng, Flora; Mitton, Craig; MacKenzie, Jennifer Jun 12, 2007

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ralssBioMed CentBMC Health Services ResearchOpen AcceResearch articlePriority setting in the provincial health services authority: survey of key decision makersFlora Teng1, Craig Mitton*2 and Jennifer MacKenzie3Address: 1Centre for Healthcare Innovation and Improvement, B.C. Research Institute for Children's and Women's Health, Vancouver, Canada, 2Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, Canada and 3Provincial Health Services Authority of B.C., Vancouver, CanadaEmail: Flora Teng - flora.teng@gmail.com; Craig Mitton* - craig.mitton@ubc.ca; Jennifer MacKenzie - jmackenzie@phsa.ca* Corresponding author    AbstractBackground: In recent years, decision makers in Canada and elsewhere have expressed a desirefor more explicit, evidence-based approaches to priority setting. To achieve this aim within healthcare organizations, knowledge of both the organizational context and stakeholder attitudestowards priority setting are required. The current work adds to a limited yet growing body ofinternational literature describing priority setting practices in health organizations.Methods: A qualitative study was conducted using in-depth, face-to-face interviews with 25 keydecision makers of the Provincial Health Services Authority (PHSA) of British Columbia. Majorthemes and sub-themes were identified through content analysis.Results: Priorities were described by decision makers as being set in an ad hoc manner, withresources generally allocated along historical lines. Participants identified the Strategic Plan and astrong research base as strengths of the organization. The main areas for improvement were adesire to have a more transparent process for priority setting, a need to develop a culture whichsupports explicit priority setting, and a focus on fairness in decision making. Barriers to an explicitallocation process included the challenge of providing specialized services for disparate patientgroups, and a lack of formal training in priority setting amongst decision makers.Conclusion: This study identified factors important to understanding organizational context andinformed next steps for explicit priority setting for a provincial health authority. While the PHSAis unique in its organizational structure in Canada, lessons about priority setting should betransferable to other contexts.BackgroundDue to limited resources, health care decision makersmust make choices about what services to fund and whatnot to fund. This process of priority setting has tradition-health care organizations, the process underlying decisionmaking is based on the previous year's expenditure beingrolled over to the current year, with some political and/ordemographic adjustments. This can lead to 'allocation byPublished: 12 June 2007BMC Health Services Research 2007, 7:84 doi:10.1186/1472-6963-7-84Received: 8 January 2007Accepted: 12 June 2007This article is available from: http://www.biomedcentral.com/1472-6963/7/84© 2007 Teng et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 10(page number not for citation purposes)ally been shaped by organizational cultures where normsand incentives have implicitly supported historically-based resource allocation processes [1]. That is, in moststealth' and enables politics to directly enter into the fray[2]. The problem is, over the last decade, decision makersin various organizations across countries have expressedBMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84dissatisfaction with these processes, desiring moreexplicit, evidence based approaches to priority setting [3-6].In order to move away from historical and/or politicallydriven allocation models, towards a more explicit, evi-dence-based process, knowledge of the organizationalcontext is required [7,8]. The reason for this is two-fold.First, sustainability of a novel process is reliant on thatprocess fitting with existing practices and beliefs. Second,understanding the context provides insight into whether amove towards an explicit priority setting process is appro-priate or desired by a given set of decision makers. Knowl-edge about current decision making practices withinhealth care organizations is thus pivotal to improving pri-ority setting processes [2,7].To better understand organizational context with respectto priority setting and to investigate the possibility ofmoving towards a more explicit process, a survey of keydecision makers was conducted in the Provincial HealthServices Authority (PHSA) of British Columbia, Canada.The objectives of this survey were: 1) to obtain insight intopast organizational practices with respect to priority set-ting; 2) to identify strengths and weaknesses of past prior-ity setting activity; 3) to determine strategies forimprovement in priority setting practices; and finally 4) todetermine likely barriers and facilitators in, and ultimatefeasibility for, moving towards an explicit process for pri-ority setting.The purpose of this paper is to present key findings of thisdecision maker survey. The findings serve to expand ourunderstanding of the organizational context within thePHSA, and through this, should provide insight into howother organizations function with respect to priority set-ting and resource allocation processes. This work buildson previous surveys that have been conducted elsewherein Canada and in Australia [5,6], and parallels ongoingresearch with health service commissioning bodies in theUnited Kingdom.MethodsContextWe conducted a survey of key decision makers from thePHSA and two of its member agencies, the British Colum-bia Children's Hospital and Mental Health Services. ThePHSA was created in December 2001 and became fullyoperational late in 2002. The PHSA is unique from theother five health authorities in British Columbia (B.C.)with its provincial, rather than regional, mandate [9]. Allsix health authorities are allocated resources directly fromthe Provincial Ministry of Health to administer andfrom the Ministry, but physicians are paid on a fee forservice basis from the Ministry and are under no contrac-tual obligation to the health authorities). Approximately70% of health care funds in Canada are generated throughprovincial and federal taxation and constitute the 'pub-licly funded' system, from which the health authoritiesreceive their funding; the remaining 30% of 'private' fund-ing is raised through out of pocket expenditure and largelyemployer-based private health care insurance.As a provider of specialized services, the PHSA coordi-nates the activities of 8 provincial agencies: B.C. CancerAgency, B.C. Centre for Disease Control, B.C. Children'sHospital and Sunny Hill Health Centre for Children, B.C.Provincial Renal Agency, B.C. Transplant Society, B.C.Women's Hospital & Health Centre, and B.C. MentalHealth Services (Forensic Psychiatric Services Commis-sion and Riverview Hospital). In addition, the PHSA isresponsible for Cardiac Services, and the provincial coor-dination of emergency and surgical services. Each agencyadministers and delivers health care in their respectiveareas, while the PHSA serves as a provincial umbrellaorganization and provides corporate services across theagencies.With the creation of the PHSA, the authority of each indi-vidual agency was transferred from the Ministry of Healthto the PHSA. A Performance Agreement was signed whichoutlined the responsibilities of both organizations. ThePHSA was mandated to achieve costs savings and managewith zero budget increases over the first three years [10].The annual operating budget of the PHSA in 2003 wasapproximately $1.2 billion [11]. With budget pressuresand growing health care costs, the PHSA was interested inexploring other options for priority setting. As a neworganization with a unique provincial mandate and anexpressed interest in priority setting, the PHSA was able toserve as a useful setting in which to better understandorganizational context with respect to priority setting andto investigate the possibility of moving towards a moreexplicit process.Study design and sampleThis is a qualitative study using data from in-depth, face-to-face interviews with key decision makers of the PHSA.All members of the PHSA Executive Team, plus the Inter-nal Assurance Officer (n = 15), were invited and agreed toparticipate in the study (Figure 1). In addition, a furtherset of decision makers from two of the PHSA's eight agen-cies (B.C. Children's Hospital, n = 5; and Mental HealthServices, n = 5) were also invited to participate on thebasis of an expressed interest in the work from the respec-tive Presidents of these two agencies and an expressedPage 2 of 10(page number not for citation purposes)deliver the majority of publicly funded health care servicesin the Province (i.e., there is no direct delivery of servicesdesire to examine their historical priority setting activity.For the Children's Hospital and Mental Health Services, aBMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84purposeful sampling strategy was employed [12],whereby a list of decision makers whose roles and respon-sibilities included priority setting was developed withinput from a senior manager within the PHSA. Five mem-bers from each agency were invited to participate and allagreed. The 10 decision-makers from the agencies wereasked their perspectives on the PHSA as a whole and ontheir views of decision-making within their own agencies,with only the data regarding the PHSA as a whole pre-sented in this paper.An initial letter describing the survey and requesting par-ticipation was sent to the potential participants. Writteninformed consent was obtained at the start of each inter-view. In total, the views of 17 administrators and 8 clini-cian administrators within the PHSA are presented in thisstudy. Written notes were made during each interview andinterviews were audiotaped with permission. The audio-tapes were independently transcribed verbatim. The inter-views were conducted between June and August 2004 bya research assistant, and thus reflect priority setting prac-tice prior to this period. The Behavioural Research EthicsBoard at the University of British Columbia (UBC)approved the study.Survey and analysisThe survey was adapted from previous surveys conductedin Australia and Alberta [1,5,13]. The interview guidecomprised 15 questions (Table 1); the questions wereasked in the order listed for each respondent. This surveyrepresents the first step in a framework for describing,evaluating and refining priority setting activity as outlinedby Martin and Singer [7]. The purpose of the survey was tounderstand the context within the PHSA as it related topriority setting activity, and to explore the potential forembarking on an explicit priority setting process withinthis organization.Feedback on the survey was obtained from the first deci-sion maker interviewed. The researchers analyzed theinterview transcripts using content analysis [14]. Majorthemes (e.g., 'stakeholder participation') and sub-themes(e.g., 'public involvement in priority setting) were devel-oped through constant comparison and categorized [14].Thus, each category was compared across the data set untilno new categories were identified. Following the firstinterview, a list of codes was developed and the survey wasrefined for subsequent interviews.During analysis, the code structure was refined once forconsistency and clarity. Once categorized, the data wereinterpreted into meaningful concepts pertaining to cur-rent and desired priority setting practices in the PHSA. Ascategories of meaning emerged, the researchers searchedfor those that had internal convergence and external diver-gence [15]. That is, the categories were constructed so thatthey were internally consistent but distinct from oneanother. Using a consistent coding structure, a researchassistant independently coded all transcripts. A secondinvestigator coded a sample of the transcripts and theresearch team met to discuss the coding structure andanalysis, with consensus reached in all cases were discrep-ancies arose.ResultsThe results are presented as follows: 1) current organiza-tional practices; 2) strengths and weaknesses of prioritysetting activity to date; 3) strategies for improvement, par-ticularly in relation to cultural change, stakeholderinvolvement, and fairness of process; and 4) barriers andfacilitators in moving forward with an explicit approachto priority setting. The data presented reflects the opinionsof key decision makers regarding priority setting at themacro-level of the PHSA. While data was also collected onthe priority setting processes of the B.C. Children's Hospi-tal and B.C. Mental Health services alone, these results arenot presented here. The survey was designed to examineprevious priority setting practices from the time the organ-ization was constituted up to the time of the interviews(late 2002 – summer 2004).Current priority setting processesThe priority setting process occurs at the level of the Exec-utive Committee in the PHSA. Decision makers within theExecutive Committee indicated that the process of prioritysetting is largely based on 'the squeaky wheel getting thegrease', and suggested that resources tend to go to 'who-ever yells the loudest'. This is exemplified by the opinionParticipants in the PHSA decision-maker surveyFigure 1Participants in the PHSA decision-maker survey. * The PHSA Executive is comprised of members from the portfolios outlined in the gray boxes. The numbers shown Internal Assurancen=1Communicationsn=1Quality ManagementPerformance Improvement& Innovationn=5B.C. Children'sHospitaln=5B.C. MentalHealth Servicesn=5Agency Presidentsn=4Support Servicesn=1Provincial ServicesPublic & PopulationHealthn=2President & CEOn=1Board of DirectorsTotal Participants*N=25Page 3 of 10(page number not for citation purposes)of this decision-maker:here represent only those who participated in the study.BMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84It's a squeaky wheel process. Whoever is able to moreclearly articulate their problem, or lobby for theirgroup or, through some other form of power andinfluence, impact whatever process is in place that yearwill come out with some outcome.Priorities were described as being set in an ad hoc manner,with resources allocated to satisfy the most people andincur the least opposition. The decision makers noted thatpriority setting usually occurs in the context of the budgetcycle and that the process is driven by historical alloca-tion. One decision maker described the process as follows:I don't think that I'm really aware of any mechanismto determine medium and long-term priorities for thePHSA. I think that it is possibly because of the newnessof the organization and, in essence, the imperative forits creation, which clearly prioritized balanced budget-ing and sustainability as being the key drivers of theshort-term. So I think when it comes to things such aspriority setting and allocation, it's really been deter-mined more by managing activity to budget than it hasbeen in terms of strategic outcomes in terms of healthcare.Decision makers stated that there had been little discus-sion of resource re-allocation across PHSA agencies, witheach agency by and large operating as its own entity. Deci-sion making criteria had been used in the past to assessalternative investment proposals in some instances, butthe criteria were not consistent throughout the PHSA.However, decision makers would routinely incorporatebest practice information when assessing options. Over-all, it was clear that decision-makers were dissatisfied withcurrent priority setting processes and desire a better frame-work by which to make decisions. One decision-makerphrased it in this manner:No, I don't think [the system] works well. I think itworks as well as it can without some more overarchingframework in which to make those decisions... Whenyou get down to it, if the decisions are, 'Should we putmore into cancer or should we put more into mentalhealth?' – who at the end of the day should actually bemaking that decision? As medical people, one canbring forward the evidence for the benefit. In terms ofthe costing, etc., one can bring the cost-effectiveness.But who actually is the beneficiary to set the priority?Strengths and weaknessesDecision makers identified a number of strengths in theirpriority setting practices. First, many respondents identi-fied the creation of the Strategic Plan as a potential organ-(i.e. other health authorities and the Ministry of Health)stakeholders and allowed them to come together to dis-cuss the future directions of the PHSA. The aim of the stra-tegic planning exercise was to establish a unified visionacross the agencies. Decision makers viewed the plan asthe first step towards a more "fair, open, and transparent"process. In theory, the goals outlined in the Strategic Planwere to created "to provide governance and direction to itsagencies in order to achieve greater levels of efficiency andeffectiveness through the consolidation of corporate serv-ices and to begin developmental work in coordinatingprovince-wide services" [16]. The Strategic Plan was offi-cially released in April 2004, only several months beforethis study was conducted.Another strength identified by decision makers was theopenness of the PHSA towards explicit priority setting.One decision maker expressed that, "despite the whiningand the gnashing of teeth, I think we're ready to move tosomething that makes a little more sense". In addition,the strong research base of the organization is a strengththat was noted, with a clear appreciation for evidence inboth policy-making and clinical practice. One decision-maker stated, "I think the fact that we have such a strongbasic and translational research infrastructure withinmany of our health care organizations within the PHSA isa real strength".Several weaknesses were also identified through the inter-views and are summarized in Table 2. Weaknesses catego-rized as 'systemic' refer to issues in the structure, policy, orsystems of the organization, while those categorized as'individual' refer to the attitudes and behaviour of individ-ual decision makers. The categories of internal and exter-nal weaknesses refer to issues within and outside of thePHSA, respectively.One systemic, internal weakness was a lack of structuraland cultural integration within the organization. This wasattributed to the recent creation of the PHSA, and relatedto the challenge noted above of re-allocating resourcesacross the agencies. In addition, decision makers said thatthere tended to be an organizational 'do-it-all' mentality,rather then an acceptance of needing to make overt ration-ing decisions. Another weakness noted by participantswas a perceived lack of authority over program areaswithin the agencies. One decision maker preferred a struc-ture where "individuals have a degree of autonomy andauthority over their area of responsibility and have someflexibility within that area to move forward, rather thanhaving to do everything at the most senior level".A perceived weakness under the individual category wasPage 4 of 10(page number not for citation purposes)izational strength. The year-long planning processincorporated both internal (i.e. employees) and externalthat decision makers would be unwilling to releaseresources from their own program budgets to fund invest-BMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84ments elsewhere. As one decision maker described, "eve-rybody thinks their business on this site is the mostimportant, that it has to be done here. It's pretty hard toset priorities when everybody thinks their thing is themost important". Yet another weakness identified bymany participants was a jaded attitude of decision makerstowards new change processes. In response to the ques-tion of how decision makers would respond to explicitpriority setting, one participant noted:"I think people would be very jaded, to start with. Itwould need to be clear that people [are] just so fedup... So I think [an explicit process] would have to bevery clear and would have to stand the test... It wouldhave to show that there was open input and that peo-ple were able to make a difference."Strategies for improvementDecisions makers identified several improvement strate-gies that would overcome the weaknesses in their prioritysetting process. The main area for improvement, noted bythe participants, was a desire to have a process that wasmore transparent and defensible (Table 3). Decision mak-the process should be defined and clearly communicatedto all stakeholders. Participants also suggested that goals,outcomes, and benchmarks for success should be defined,using the PHSA Strategic Plan as a guide. The consistentapplication of the process was also seen as integral to anyplan. In addition, it was felt that any process should betime-sensitive and driven by evidence. As one decision-maker noted, there is a strong research base of the organ-ization, but the use of this evidence could be improved.We have a strong base of research in all of our organi-zations [agencies], so there is probably more evidenceout there about what works and what doesn't workthan we currently use in our resource allocation prac-tices."Decision makers further stated a need for developing aculture that supports explicit priority setting. It was sug-gested that this could be achieved through education ofinternal stakeholders and the demonstration of realresults. The former was viewed as a key component toincreasing awareness about explicit priority setting, whilethe ability to demonstrate results was seen as a way to pos-Table 1: Interview guide1 Can you describe for me the process that is currently used to identify priorities and allocate resources within the PHSA?2 Overall, do you think the process works well? What are the strengths of the process?3a How well is the publicity condition met in this organization?*3b How well is the relevance condition met in this organization?*3c How well is the appeals condition met in this organization?*3d How well is the enforcement condition met in this organization?*4 How can the current process of setting priorities and allocating resources be improved?5 What types of information (or data or evidence) that are not currently used would you most want to use to improve decision making in setting priorities and allocating resources?6 What barriers are currently faced in undertaking the priority setting process within the PHSA?7 Noting the organizational culture of the PHSA, how would this environment respond to a move towards an explicit, more formal, process of priority setting?8 How do the group dynamics at a typical executive meeting impact priority setting decisions?9 What factors do you think are necessary for sustaining an explicit, more formal, priority setting process in the PHSA? Please be as specific as possible.10 How has the public been used in priority setting/resource allocation processes in the past?11 Ideally, how would you want the public to be involved in the priority setting process?12 What role have physicians played in priority setting/resource allocation processes in the past?13 Ideally, how would you want the physicians to be involved in the priority setting process?14 How well do you think the values of the PHSA are incorporated into priority setting activity?15 How should the values of the PHSA be incorporated into the priority setting process?*These questions are based upon an ethical framework called Accountability for Reasonableness [19], with details of each ethical 'condition' presented to the respondents prior to eliciting their responses.1 Condition of relevance: Decisions should be made on the basis of reasons (i.e. evidence, principles, values, arguments) that 'fair-minded' stakeholders can agree are relevant under the circumstances; Publicity: Decisions and their rationales should be made available to stakeholders; Revision and appeals: There should be opportunities to revisit and revise decisions in light of further evidence or arguments, and there should be a mechanism for challenge and dispute resolution; Enforcement: There is a voluntary or regulatory mechanism for ensuring that the other three conditions are met. Condition of relevance: Decisions should be made on the basis of reasons (i.e. evidence, principles, values, arguments) that 'fair-minded' stakeholders can agree are relevant under the circumstances; Publicity: Decisions and their rationales should be made available to stakeholders; Revision and appeals: There should be opportunities to revisit and revise decisions in light of further evidence or arguments, and there should be a mechanism for challenge and dispute resolution; Enforcement: There is a voluntary or regulatory mechanism for ensuring that the other three conditions are met.Page 5 of 10(page number not for citation purposes)ers suggested that such a process should take both contextand politics into consideration. In addition, a vision foritively reinforce the benefit of a new process and contrib-ute to its continued use.BMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84While the PHSA currently uses stakeholder opinion in pri-ority setting, decision makers believed that stakeholderinvolvement could be improved. Participants stated thatthe general public was not involved in priority setting todate. The main reason cited for this was the difficulty offinding the right forum to garner public opinion. Onedecision maker described this predicament:The public can be important, unquestionably, becausethat's really the only way one can put social contextaround how taxpayers' dollars get spent. So I don'thave any difficulty with that context. How you engagethe public and what you ask the public becomes a verydifficult issue for consideration, because one can'treally hold a Town Hall Meeting and say, "Wherewould you like your money spent – on mental healthor cancer?"Decision makers believed that while it was important toobtain public opinion, the ideal role of the public wouldbe involvement at a fairly general level. For example, itwas felt that ascertaining the public's opinion on broadareas of importance would be more useful than input onspecific decisions. Participants suggested that this couldbe done through surveys, public forums, focus groups, orhaving a member of the public at the decision makingtable. One decision maker described what they viewed asthe ideal role for the public:I think the public would have to be involved at a veryhigh level in deciding what the general goals and val-ues are that one makes a decision around. They needto say "this is what is important for them" and thenleave it to decision makers to apply those values totheir decision making process and its up to the boardIn addition to the role of the public, participants were alsoasked about the role of physicians in priority setting.Many decision makers believed that physician-stakehold-ers were quite involved in priority setting already, but thattheir involvement could be improved. The majority ofdecision makers felt that the ideal role of physicianswould be to bring clinical evidence to the table. Partici-pants also noted that physicians face an inherent conflictof interest. With a fee-for-service system, physicians havean incentive to utilize services rather than conserveresources. This incentive can create difficulties in allocat-ing system resources in the most efficient manner. It wassuggested that physician training in management practicewould be useful.Another area of improvement cited by decision makerswas the issue of fairness in priority setting. In the PHSA,participants noted that most decisions were publiclyannounced, but the rationale and decision making proc-ess behind the decisions were not publicly available.Despite this, participants believed that as a whole deci-sions were data-driven. Many decision makers also notedthat there was no formal mechanism for appealing alloca-tion decisions. As a result, decision makers did not believethat adequate enforcement existed to ensure that deci-sions were made in a fair and equitable manner. Overall,decision makers believed that components of the prioritysetting process could be considered fair, but that furtherimprovement was required.Barriers and facilitators for changeDespite the desire for greater transparency, decision mak-ers identified a number of barriers that would hinder amove towards an explicit process based on the notion ofre-allocating resources across service areas. One barrierTable 2: Perceived weaknesses in priority setting in the PHSASystemic InternalCentral decision making creating a feeling of disempowerment among managersLack of true accountability to conserve resources"Do it all" mentality that prevents the organization from identifying disinvestmentsIncentive to overspend because efficiency is not rewardedLack of structural and cultural integration due to the recent creation of the PHSAExternalConfusion regarding role and authority of the BC Ministry of Health and the PHSALimitations in priority setting due to provincial mandate and global priority settingIndividual Lack of priority setting skills and tools which support resource re-allocationUnwillingness to release resources from own budgets to fund investments elsewhereFear of being explicit in priority settingDecision makers jaded to change processes because of too much change in the institutionLack of management training for physician-leadersPage 6 of 10(page number not for citation purposes)be the governors to ensure that decision makers areapplying that on their behalf.was the mandate of providing specialized services. ThePHSA is comprised of eight highly specialized agencies,BMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84which serve widely differing populations. With this man-date, decision makers must set priorities knowing thatthey are the only organization providing that service.Decision makers stated that setting priorities in this con-text can be quite difficult and that they do not feel theyhave the right tools to inform such decisions.If you were to take something away from a place... it'snot as though you could say, 'Okay, we're not going todo this at [Hospital A], but they can go to [HospitalB].' For the tertiary stuff that we do here, you can't dothat, because there's no place else in the province. It'snot as though we could say, 'Okay, we're not going todo that here, but somebody else will do it.' That, Ithink, is a significant barrier.Other barriers identified in moving to an explicit prioritysetting process were a lack of shared vision in the PHSA, alack of priority setting skills among the managementteam, and the lack of decision maker buy-in for such amove. In addition, decision makers noted that there was alack of real or perceived authority to change the processand a significant political influence in priority setting.According to one decision-maker:What tends to happen, I think, is that new programsget funded on the basis of politics, not on the basis ofneed or priority setting. So these last two or three yearsthere's been money for autism – nothing to do withus; everything to do with politics. Five years beforethat it was eating disorders. Again, the politiciansbecame involved and said, 'We must have an eatingdisorder program.' They didn't come to us and ask uswhat we wanted. They get very much involved in themicro-management and allocation process.In addition, a lack of budget integration across agencies isa major barrier to explicit priority setting. On this issue,one decision maker stated that the PHSA has taken "awhole bunch of agencies and put them together, and alltheir budgets together with them." Participants com-To counterbalance the barriers for change, decision mak-ers also highlighted several facilitators that would need tobe fostered to aid in the implementation of an explicit pri-ority setting process. These included a strong leadershipteam and commitment to explicit priority setting, as wellas consistent application of the process, demonstratedresults and an adequate amount of resources for re-alloca-tion across services. One decision maker described theimportance of strong leadership and commitment to pri-ority setting:I think fundamentally we have to have 100 percentcommitment from the board and CEO. It's always thesame. If they're not really committed to [it], then it'sprobably not going to be well endorsed.In addition, a culture of openness to priority setting, a cul-ture of learning, and a data-driven culture were cited asimportant facilitators that currently existed in the organi-zation, which would assist in the implementation of anexplicit priority setting process.DiscussionSummary of findingsThis study is the first to our knowledge to examine theviews of health care decision makers on priority settingand organizational context in British Columbia. Thisstudy is also novel in its examination of a provinciallybased health authority. Almost all other health authoritiesin Canada have a regional rather then provincial focus.Through this survey we assessed the process of priority set-ting, the strengths and weaknesses to priority setting,improvements that could be made to make an explicitprocess feasible, organizational barriers that exist andfacilitators that could be drawn upon to support anexplicit approach.The survey builds on previous studies in other jurisdic-tions which have examined decision maker views onaspects of priority setting. This type of approach has beenshown elsewhere to be an important precursor to theTable 3: Strategies for improvementIncrease transparency and accountability • Make the decision making process more transparent and accountable to internal and external stakeholdersCreate explicit process • Align process with organizational context and account for politics• Clearly communicate vision of the process to all stakeholders• Define goals, outcomes, and benchmarks for success incorporating the Strategic PlanInitiate cultural change • Create time-sensitive, evidence-driven process• Apply the process in a consistent manner• Provide education to create a culture of explicit priority settingIncrease stakeholder involvement • Include public opinion at a general level and provide management training for physiciansEnhance fairness • Create explicit appeals process for priority setting decisionsPage 7 of 10(page number not for citation purposes)mented that with the barriers of an historical structure, itis difficult to shift resources across agency lines.development and implementation of an explicit approachto priority setting in health organizations [5,6,17]. OurBMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84results confirm the importance of gaining an understand-ing of organizational context prior to embarking on a newapproach to priority setting, and add to the health policyliterature by identifying key organizational barriers andfacilitators to such activity.Examination of key resultsAt the time of the survey, a historical approach was themain mechanism for allocating scarce resources. This issimilar to priority setting processes described in otherhealth organizations in Canada, the United Kingdom, andAustralia [5,6,17]. It is clear that decision makers are dis-satisfied with this mechanism for allocating resources anddesire a more explicit, evidence-based approach. This isnot surprising as decision makers are being pressured tobe more transparent and accountable in their decisionmaking [18]. The recent literature on ethics suggests agrowing interest in the fairness of priority setting proc-esses [7,19,20].Decision makers in the PHSA indicated that they wouldlike more involvement from key stakeholders in their pri-ority setting processes. They suggest that the optimal formof public involvement is through consultation in broadterms on issues of values and overall health priorities. Thisgives credence to findings from both Australia [5] and therecent Romanow Commission report in Canada whichsuggest that decision makers support a more general rolefor the public [21]. Organizational context also plays arole in how the public is engaged in decision-making.Abelson notes that organizations have the capacity toexert a strong "enabling" influence on public participa-tion, the outcomes of which are dependent on the exist-ence of a participatory culture and the amount of timethat the culture has been in place [22].With respect to physicians, decision makers supported astronger physician role as the bearers of clinical evidenceand the medical interpreters for management. Decisionmakers also felt that physicians would be in the best posi-tion to inform decision makers on what is considered bestpractice within each specialty, and to assist in discerningpriorities accordingly. The role of physicians in manage-ment processes more generally has been a topic of muchconcern for a number of years [23,24]. Our results suggestseveral ways in which physicians can be involved in thearea of priority setting and resource allocation. One keyrole for physicians in resource allocation would be toserve as the bearers of clinical evidence. It would also bebeneficial for physicians to interpret the scientific evi-dence and translate that knowledge alongside of policymakers in resource allocation decisions. It should benoted that about one quarter of participants in our studyFinally, the decision makers in the PHSA had yet toundergo an explicit priority setting exercise, but were ableto provide insight into the perceived barriers and facilita-tors to an explicit process (see Figure 2). The results can bedivided into barriers and facilitators prior to embarkingon an explicit priority setting process and those thatimpact the sustainability of recommendations. Thismodel extends previous work on organizational behaviorwith respect to priority setting. Key factors for successinclude a lack of shared vision in priority setting, compet-ing priorities, vested interest, the importance of demon-strated results, and a data-driven culture. While some ofthese parameters have been highlighted in other studies[8,17,25-27], we are adding to this literature the context ofa provincial health authority and to our knowledge this isthe first time that these additional factors have been pre-sented in one empirical model.From theory to practiceBased on the findings from this survey, PHSA was notready to engage in an explicit priority setting process thatinvolves re-allocating resources across the organization.The primary rationale for this is the lack of integrationthat exists within the PHSA. According to Denis et. al.(2004), a sense of unified culture impacts the level of inte-gration in an organization, which in turn impacts the easeby which priority setting can occur across the organization[28]. This can be attributed in part to infancy of the organ-ization, the specialized nature of care in the PHSA, andstrong history of each of the member agency. In addition,unlike regional health authorities which can often inte-grate services [29], it is more difficult between the agenciesof the PHSA because of the specialized nature of care.However, the desire of decision makers within the PHSAto adopt a formal approach to priority setting lead theExecutive to develop a decision tool to impact prioritiza-tion of new service initiatives for the 2005/06 budgetcycle. This tool, reported elsewhere [30], involved devel-opment and definition of eight key decision criteria andthen rating a number of investment proposals against thecriteria to derive an overall benefit score for each serviceoption. Following its implementation in the first year,refinements were made and the tool was again employedfor the 2006/07 budget cycle prioritization process. Keyrefinements included improvements to the criteria as wellas greater process transparency through stronger commu-nication efforts.It is also important to note that in the current survey deci-sion makers discussed that an explicit approach to prioritysetting could begin at the agency-level where resource re-allocation is likely to be more feasible and program man-Page 8 of 10(page number not for citation purposes)(n = 8/25) were themselves physicians. agers are more familiar with shifting resources. Theseagencies could serve as 'change agents' [31], which overBMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84time can influence other parts of the organization. Someof this activity has been started, although formal follow-up is required to report activity in any detail. In movingforward, the key will be to continue to foster a transpar-ent, consistent, and defensible approach. Ongoing educa-tion will also be required, and, in order for continuedcommitment, real results will have to be demonstrated.LimitationsThe main limitation of this study is that we examineddecision maker perceptions about priority setting beforethey had the opportunity to engage in an explicit processand reflect on its strengths and weaknesses. However, itwas not the focus of this phase of the research to under-take an explicit priority setting case study. The purposeutilized in later stages of the research as discussed in thepreceding section.TransferabilityThis study was conducted in a provincial health authorityin British Columbia. This health authority is the only oneof its kind in Canada and the survey highlights someissues that are unique to the PHSA. However, this healthauthority faces many of the same issues found in otherhealth organizations in Canada and elsewhere. For exam-ple, case studies in Australia, Alberta, and the UK describedifficulties in resource re-allocation and a desire forgreater transparency in decision making. In comparingour results to findings elsewhere, it would seem thatorganizational context does not greatly differ between dif-PHSA organizational context modelFigure 2PHSA organizational context model. *Additions to model extending work from Mitton and Donaldson [19].Explicit priority setting process OutputsBarriers - no genuine buy-in - lack of skills in priority setting - lack of shared vision* - competing priorities*Barriers- vertical budget silos - politics trumps evidence-based decisions - no (real or perceived) authority to change - vested interest* - misalignment of incentives Facilitators - high level champion; strong leadership - culture of learning - earmarked resources for process - commitment to process*Facilitators- culture open to change - earmarked resources for follow-up - consistent application* - demonstrated results* - data-driven culture*InputsIdeal Process* - Clear communication of vision - Integrate strategic goals - Time-sensitive - Evidence-based - Input from stakeholders Page 9 of 10(page number not for citation purposes)was to examine organizational context and other anteced-ent conditions related to priority setting, which were thenferent types of health care organizations in different coun-tries. Thus, the results of this study are likely transferableBMC Health Services Research 2007, 7:84 http://www.biomedcentral.com/1472-6963/7/84to other settings where decision makers have to makedecisions amongst competing claims under constrainedresources. This would include the above countries, andindeed Western Europe, and even the United States, whereHMOs face similar constraints of resource scarcity andlimited budgets [2].ConclusionTo date, there has been limited research pertaining to theorganizational context within which difficult fundingdecisions are made. As well, few organizations have uti-lized this information to guide the development ofexplicit priority setting processes. The qualitative surveyreported herein provides insight into the impact of con-text on an organization grappling with priority setting andwas an important precursor to informing the next steps fordeveloping an explicit approach in the PHSA. This workcontributes to the growing body of literature on organiza-tional behaviour and priority setting, and should be ofvalue for decision makers and researchers interested inpriority setting and resource allocation processes.Competing interestsJM is a paid employee of the Provincial Health ServicesAuthority of BC.Authors' contributionsFT took the lead on drafting the paper. CM and JM madesubstantial intellectual contributions including input onstudy design, sample selection, questionnaire develop-ment and data analysis.AcknowledgementsThe authors would like to thank Angela Bate, University of Newcastle Upon Tyne, UK, and Kristy Armstrong, University of B.C., for their helpful comments on this paper. We are also grateful for the comments of the two peer-reviewers. Craig Mitton holds a Michael Smith Foundation for Health Research Scholar Award and a Canada Research Chair in Health Care Pri-ority Setting. The views expressed are those of the authors, not the Pro-vincial Health Services Authority of BC.References1. Mitton CR, Donaldson C: Setting priorities and allocatingresources in health regions: lessons from a project evaluat-ing program budgeting and marginal analysis (PBMA).  HealthPolicy 2003, 64:335-348.2. Mitton C, Donaldson C: Priority Setting Toolkit: A guide to theuse of economics in healthcare decision making.  London, BMJPublishing Group; 2004:183. 3. Vale L: Programme Budgeting: Key Decision Makers Survey.Aberdeen, Grampian Health Board; 1996. 4. Miller P: Managing informed purchasing: a survey of decisionmakers.  J Managed Med 1997, 11(1):35-42.5. Mitton C, Prout S: Setting priorities in the south west of West-ern Australia: where are we now?  Aust Health Rev 2004,28:301-310.6. Mitton C, Donaldson C: Setting priorities in Canadian regionalhealth authorities: a survey of key decision makers.  Health Pol-icy 2002, 60:39-58.8. Jan S: A perspective on the analysis of credible commitmentand myopia in health sector decision making.  Health Policy2003, 63:269-278.9. Cranston L, Powell W: Leveraging Strengths, TransformingHealth Care, The PHSA Strategic Plan.  Vancouver, ProvincialHealth Services Authority; 2004:68. 10. PHSA: PHSA moving forward with health services designplans announced in 2002/03.   [http://www.phsa.ca].11. PHSA: PHSA invests more dollars in life support, vaccines.[http://www.phsa.ca/].12. Glaser BG, Strauss AL: The discovery of grounded theory: strat-egies for qualitative research.  Chicago, Illinois, Aldine; 1967. 13. Mitton C, Patten S: Evidence-based priority-setting: what dothe decision-makers think?  J Health Serv Res Policy 2004,9:146-152.14. Pope C, Ziebland S, Mays N: Qualitative research in health care:Analyzing qualitative data.  BMJ 2000, 320:114-116.15. Lincoln YS, Guba EG: Naturalistic Inquiry.  Beverly Hills, Sage Pub-lications Inc.; 1985. 16. PHSA: Leveraging Strengths...Transforming Health Care:The PHSA Strategic Plan.   [http://www.phsa.ca/].17. Miller P, Vale L: Programme approach to managing informedcommissioning.  Health Services Management Research 2001,14(3):159-164.18. Dubrow MJ, Goel V, Upshur REG: Evidence-based health policy:context and utilisation.  Soc Sci Med 2004, 58:207-217.19. Daniels N, Sabin J: The ethics of accountability in managed carereform.  Health Affairs 1998, 17:50-64.20. Giacomini M, Hurley J, Gold I, Smith P, Abelson J: The policy anal-ysis of 'values talk': lessons from Canadian health reform.Health Policy 2004, 67:15-24.21. Shiell A, Mooney G: A framework for determining the extentof public financing of programs and services.  Commission on theFuture of Health Care in Canada Discussion Paper No 6 2002.22. Abelson J: Understanding the role of contextual influences onlocal health-care decision making: case study results fromOntario, Canada.  Soc Sci Med 2001, 53(6):777-793.23. Martin D, Abelson J, Singer P: Participation in health care prior-ity-setting through the eyes of the participants.  J Health ServRes Policy 2002, 7:222-229.24. Morreim EH: Balancing act: the new medical ethics of medi-cine's new economics.  Volume 2. Washington, DC, GeorgetownUniversity Press; 1995. 25. Kotter JP: Leading change: why transformation efforts fail.Harvard Business Review 1995:59-67.26. Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ,Krumholz HM: A qualitative study of increasing beta-blockeruse after myocardial infarction. Why do some hospitals suc-ceed?  JAMA 2001, 285:2604-2611.27. Lomas J, Woods J, Veenstra G: Devolving authority for healthcare in Canada's provinces: 1. An Introduction to the issues.CMAJ 1997, 156:371-377.28. Denis JL, Contandriopoulos D, Beaulieu MD: Regionalization inCanada: a promising heritage to build on.  Healthcare Papers2004, 5:40-45.29. Lewis S, Kouri D: Regionalization: making sense of the Cana-dian experience.  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