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Difficult decisions in times of constraint: Criteria based Resource Allocation in the Vancouver Coastal… Mitton, Craig, 1972-; Dionne, Francois; Damji, Rizwan; Campbell, Duncan; Bryan, Stirling 2011-07-14

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CORRESPONDENCE Open AccessDifficult decisions in times of constraint: Criteriabased Resource Allocation in the VancouverCoastal Health AuthorityCraig Mitton1,2*, Francois Dionne1,2, Rizwan Damji3, Duncan Campbell3 and Stirling Bryan1,2AbstractObjectives: The aim of the project was to develop a plan to address a forecasted deficit of approximately $4.65million for fiscal year 2010/11 in the Vancouver Communities division of the Vancouver Coastal Health Authority.For disinvestment opportunities identified beyond the forecasted deficit, a commitment was made to consideroptions for resource re-allocation within the Vancouver Communities division.Methods: A standard approach to program budgeting and marginal analysis (PBMA) was taken with a prioritysetting working committee and a broader advisory panel. An experienced, non-vested internal project managerworked closely with the two-member external research team throughout the process. Face to face evaluationinterviews were held with 10 decision makers immediately following the process.Results: The recommendations of the working committee included the implementation of 44 disinvestmentinitiatives with an annualized value of CAD $4.9 million, as well as consideration of possible investments if therealized savings match expectations. Overall, decision makers viewed the process favorably and the primary aim ofaddressing the deficit gap was met.Discussion: A key challenge was the tight timeline which likely lead to less evidence informed decision makingthen one would hope for. Despite this, decision makers felt that better decisions were made then had the processnot been in place. In the end, this project adds value in finding that PBMA can be used to cover a deficit andminimize opportunity cost through systematic application of criteria whilst ensuring process fairness throughfocusing on communication, transparency and decision maker engagement.Keywords: priority setting, health care decision-making, disinvestmentBackgroundAs part of the fallout from the 2008 global economiccrisis there has been extreme pressure on public sectorspending. Across most countries, including Canada, def-icits have increased dramatically leaving governmentdepartments having to either identify operational effi-ciencies or cut services. In the rare instance where addi-tional investment in a particular area is made, suchexpansion is only achievable at a very real and poten-tially crippling effect on other departments, as wasrecently the case in the Province of Alberta.Interestingly, recent polls in Canada suggest that mem-bers of the public favor a reduction in public sector ser-vices over increases to income tax or sales tax.However, when specific cuts are identified, the cries ofinjustice are quick to make front-page news.The fact is there are only so many resources to goaround. This has been well documented in the healthsector for many years and thus clearly pre-dates themost recent recession. What perhaps has made therecent move toward cuts in health care less palatable isthat, in Canada as elsewhere, this has followed on thewake of over a decade of year on year real increases inexpenditure. Nonetheless, the notion of decommission-ing of health services has started to gain some traction.For example, the UK’s National Institute of Health and* Correspondence: craig.mitton@ubc.ca1Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal HealthResearch Institute, Vancouver, CanadaFull list of author information is available at the end of the articleMitton et al. BMC Health Services Research 2011, 11:169http://www.biomedcentral.com/1472-6963/11/169© 2011 Mitton et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.Clinical Excellence (NICE) recently indicated a focus onappraisal of not only technologies for investment butalso areas for disinvestment [1]. Several recent papershave also addressed the issue of disinvestment, discuss-ing potential avenues for such action [2].The Program Budgeting and Marginal Analysis (PBMA)framework was implemented in the Vancouver CoastalHealth Authority (VCH) on a pilot basis from January toMarch 2010. VCH is one of six health authorities in Brit-ish Columbia and with an annual operating budget ofapproximately CAD $3B provides services across the fullcontinuum of care for about one million residents inMetro Vancouver. The specific focus of the exercise waswithin Vancouver Community Services, a major divisionwithin the health authority providing a mix of direct andcontracted-out non-acute services. The primary aim of theproject was to develop a plan to address the forecasteddeficit of approximately $4.65 million for fiscal year 2010/11 on a $280 M budget. For disinvestment opportunitiesidentified beyond the forecasted deficit, a commitmentwas made to consider options for resource re-allocationwithin the Vancouver Communities division.This paper outlines the approach taken with respect toPBMA implementation and provides results that fol-lowed in terms of real decisions by the Senior ExecutiveTeam of the health authority. Lessons learned and areasfor improvement are also described based on findingsfrom a formal post-exercise evaluation with key decisionmakers. One challenge of PBMA identified in the pasthas been difficulty in generating and acting upon disin-vestment options [3]. This action research project pro-vides an example of success in terms of achievingdisinvestments and thus factors for this are explored. Inthis, we consider the question as to whether PBMA canonly have a large impact on disinvestment if there isexternal fiscal pressure. This paper should be acutelyrelevant to health care decision makers facing potentialcuts of their own, as well as health services researcherslikely to be called upon to support such activity.MethodsA standard approach to PBMA was taken [4], with apriority setting working committee comprised of allDirectors and Clinical Leads from Vancouver Commu-nities (n = 15), as well as a broader Advisory Panel thatincluded a mix of Vancouver Communities personneland Senior Executive members (n = 8). The AdvisoryPanel reported to the Senior Executive Team, which hasfinal decision-making authority within the organizationsubject to Board approval as necessary. An experienced,non-vested internal project manager worked closely withthe two-member external research team throughout theprocess. The research team acted as participant obser-vers within an action research frame. The functions ofeach group are outlined in Table 1. The steps followedfor PBMA implementation are depicted in Figure 1.Operating on tight timelines (2.5 months total for pro-cess development, implementation and final decisionmaking), process features included a formal communica-tion plan, clearly defined, weighted assessment criterialinked to the strategic priorities of the health authority,a proposal rating tool and use of a standard businesscase template. The research team provided the workingcommittee with a straw man set of criteria that wereadapted and refined through several iterations. The cri-teria and rating tool are presented in Table 2. Criteriawere weighted by a set of internal stakeholders througha simple point-allocation method. This involved askingapproximately 20 managers and clinical leaders withinVCH who were involved in the Vancouver CommunitiesDivision to allocate 100 points across the establishedcriteria. A mean for each criteria was then calculatedwhich was used as the weight in deriving the benefitscore.Managers within Vancouver Communities submittedproposals for disinvestment and then investment to theworking committee for assessment and ranking, withrecommendations forwarded to the Advisory Panel. As adetailed program evaluation had previously been con-ducted, managers were intimately aware of the servicesacross the program areas in this division. In some casesliterature and other sources of information includingbenchmarking and practice patterns elsewhere weredrawn on to develop proposals. In all cases, the type ofevidence base for the given proposal was identified inthe business case submission. Areas of care within theTable 1 Groups and rolesGroups RolesPriority setting working committee (Directors and ClinicalLeads within Vancouver Communities division)Actual implementation of PBMA, e.g., establishing criteria, deciding on processguidelines, rating of proposals, recommendations to Advisory PanelPBMA Advisory Panel (mix of Vancouver Communitiespersonnel and Senior Executive Team members)Oversight of PBMA implementation, approval of the process guidelines, criteria andratings, providing recommendations to the Senior Executive TeamSenior Executive Team (CEO and direct reports) Review of the process recommendations and decisions on these recommendations(subject to Board approval)Research team Facilitators, process stewards, non-voting observers at working committee andadvisory panel meetingsMitton et al. BMC Health Services Research 2011, 11:169http://www.biomedcentral.com/1472-6963/11/169Page 2 of 11scope of the exercise are listed in Table 3, which consti-tuted just under half of the total budget of the Vancou-ver Communities division. Issues related to scope areaddressed below.The research team conducted an evaluation of theexercise immediately following announcement of finaldecisions by Senior Executive. The primary objectivewas to identify areas of improvement and assess possibleexpansion of PBMA to other areas within the healthauthority. Between March 23 and April 13, 2010, 10decision-makers were interviewed face to face. Potentialrespondents were purposively selected by the researchteam to provide representation in terms of background(clinical and management) and level within the organi-zation. The researchers held the identity of the respon-dents in confidence. The semi-structured interviewswere audio taped and a thematic analysis was con-ducted. The results presented here focus on training,framework implementation, and future opportunities forPBMA within the health authority.External ethics board approval was not sought for thisproject, as all of the people involved were health author-ity decision makers who were acting in the course oftheir normal duties. Further, the interviews to informthe evaluation were conducted solely to improve futureimplementation in the health authority.ResultsThe recommendations of the working committeeincluded the implementation of 44 disinvestment initia-tives with an annualized value of $4.9 million, as well asconsideration of possible investments if the realized sav-ings match expectations. These recommendations wereapproved by the Advisory Panel and then presented toSenior Executive on March 23, 2010. At that meeting,Senior Executive agreed to implement all of the processrecommendations regarding disinvestments and to sup-port further development of a limited set of investmentoptions. For the latter, a preliminary list of investmentoptions was established by the working committee forassessment of relative value against remaining disinvest-ment options that would not be used to meet the deficit.The working committee and Advisory Panel supportedthis conservative approach prior to receiving approvalby the Senior Executive. The working committee in par-ticular felt that expectations would be best held incheck by not prematurely introducing a lengthy (andultimately unrealistic) list of investment options.The ranked disinvestment initiatives are presented inTable 4 (with actual program names removed), alongwith preliminary investment options in Table 5. Shouldfurther work on investments be pursued, the next stepin this work would be to make relative value compari-sons of each investment option to the next lowestranked (i.e., least beneficial) disinvestment option,beyond that which was required to meet the deficit. Ifan investment option is deemed to be of greater valuethen the benefit lost by acting on the disinvestmentoption, a recommendation for resource re-allocationwould ensue. Over time, such changes ‘at the margin’would lead to improvements in the overall spendingbased on how well the objectives of the organization (asreflected through the criteria) are being met. As statedabove, the primary aim of the exercise was to meet thedeficit; changes beyond this were to be considered butwere discretionary.The results from the evaluation interviews arereported for three major themes: training, implementa-tion and future use. Overall feedback on the trainingprovided at the start of the project was positive. Themain strengths of the training were that it was: focused(i.e. that it dealt with what was necessary to implementthe PBMA process); direct (i.e. that it avoided jargonand was presented clearly and concisely); and relevant (i.e. it incorporated the use of examples that were mean-ingful to the participants). One concern that was raisedwith respect to training was that some participants hada misunderstanding early on about what specificallyPBMA would do. That is, some of the participantsexpected PBMA to take the form of program evaluationwhereby a ranking of all programs within VancouverCommunities would result. Additional time wasrequired during training to explain that PBMA focuseson changes to services and the marginal or incrementalbenefit gain (or loss) from implementing a specific pro-posal. This has important ramifications because thefocus of PBMA is on shifting the levels of service asopposed to complete deletion or novel introduction of aprogram (although in the extreme a shift in level couldindeed be to fully eliminate or introduce a program). InPriority Setting Framework23415 543211 3 5 211. Determine aim & scopeof decision making.4. Develop decision criteriawith stakeholder input.3. Clarify existing resource mix.5. Identify & rank funding options or strategic initiatives.7. Provide formal decision review process.8. Evaluate & improve.6. Communicate decisionsand rationale.2. Identify priority settingcommittee.Figure 1 PBMA approach as implemented in VCH.Mitton et al. BMC Health Services Research 2011, 11:169http://www.biomedcentral.com/1472-6963/11/169Page 3 of 11Table 2 Criteria and rating scale*DOMAIN DomainWeightsCRITERIA DEFINITION CriteriaWeightRATING SCALE-3 -2 -1 0 1 2 3Alignment toMandate1) The service is directlyrelated to health care orpreventative health2) The service is notprovided by anotherorganization outside VCH15 Strongalignment withmandate (forreleases)Moderatealignment withmandate (forreleases)Weakalignment withmandate (forreleases)No alignmentwith mandate(for releases orinvestments)Weakalignment withmandate (forinvests)Moderatealignment withmandate (forinvests)Strongalignment withmandate (forinvests)3) The service is not theresponsibility of anorganization outside VCHStrategicalignment30 Efficiency,EffectivenessandAppropriate-ness1) Optimal use ofresources to yieldmaximum benefits andresults,2) Care that is known toachieve intendedoutcomes5 Goes againstfour or five ofthe fiveobjectivesGoes againsttwo or threeof the fiveobjectivesGoes againstone of the fiveobjectivesNo net impact Supports oneof the fiveobjectivesSupports twoor three of thefive objectivesSupports fouror five of thefive objectives3) Care provided isevidence based andspecific to individualclinical needs4) Promote wellness &prevention initiatives5) Support clients athome/returning home orself managementAccess Impact on timely accessto appropriate healthcare services for definedpopulation(s). Note: the‘defined populations’ arethose using the servicesaffected by the proposedchanges.5 Significant(more than10%)worsening ofthe waitingtimes for morethan 20% ofthe populationor completeclosure of aserviceSignificant(more than10%)worsening ofthe waitingtimes 10% to20% of thepopulation orclosure of aservice formore than25% of thetimeSignificant(more than10%)worsening ofthe waitingtimes for lessthan 10% ofthe populationor closure of aservice for lessthan 25% ofthe timeNo impact Significant(more than10%)improvementof the waitingtimes for lessthan 10% ofthe populationor expansionof hours byless than 25%Significant(more than10%)improvementof the waitingtimes for 10%to 20% of thepopulation orexpansion ofthe hours bymore than25%Significant(more than10%)improvementof the waitingtimes for morethan 20% ofthe populationor opening ofa new servicefacility (not areplacement)Mittonetal.BMCHealthServicesResearch2011,11:169http://www.biomedcentral.com/1472-6963/11/169Page4of11Table 2 Criteria and rating scale* (Continued)Flow/IntegrationImpact on thecoordination of healthcare services amongprograms to ensure flowand continuity of carefrom the patient’sperspective (improve flowtransitions)5 Negativeimpact oncontinuity formore than20% of clientsor significantworsening forsome patientsNegativeimpact oncontinuity for10% to 20% ofclientsNegativeimpact oncontinuity for5% to 10% ofclientsImpact on lessthan 5% ofclientsImprovementin continuityfor 5% to 10%of clientsImprovementin continuityfor 10% to20% of clientsImprovementin continuityfor more than20% ofpatients orsignificantimprovementfor someclientsHealth Impact 45 NumbersaffectedNumber of individualsaffected by the proposedchange8 More than1500 have lessservices251 to 1500have lessservices1 to 250 haveless services0 1 to 250 havemore services251 to 1500have moreservicesMore than1500 havemore servicesEquity Impact on the healthstatus of recognizedgroups where there is aknown health status gap.10 More than50% of thoseaffected are inthe mostdisadvantagedgroups(releases)More than50% of thoseaffected are inmoderatelydisadvantagedgroups(releases)10% to 50% ofthose affectedare in themostdisadvantagedgroups(releases)Less than 50%of thoseaffected are inmoderatelydisadvantagedgroups(releases orinvestments)10% to 50% ofthose affectedare in themostdisadvantagedgroups(invests)More than50% of thoseaffected are inmoderatelydisadvantagedgroups(invests)More than50% of thoseaffected are inthe mostdisadvantagedgroups(investments)Significance ofimpactImpact on clinicaloutcomes for the patient/client, including risk ofadverse events, ascompared to currentpractice/service.11 Significantnegativeimpact (eithermore than25% ofaffected clientssuffer negativeeffects orsome clientsaresignificantlyaffected)Moderatenegativeimpact (10%to 25% ofaffected clientssuffer negativeeffects)Small negativeimpact (5% to10% ofaffected clientssuffer somenegativeeffects)Less than 5%of affectedclientsexperience anychanges insatisfaction ofsafetySmall positiveimpact (5% to10% ofaffected clientsenjoy somepositiveeffects)Moderatepositive impact(10% to 25%of affectedclients enjoypositiveeffects)Significantpositive impact(either morethan 25% ofaffected clientsenjoy positiveeffects orsome clientsaresignificantlyaffected)Healthpromotion anddiseasepreventionImpact on illness and/orinjury prevention, well-being and harmreduction as measuredby projected longer termimprovements in health8 Significantnegativeimpact onburden ofdiseaseModeratenegativeimpact onburden ofdiseaseSmall negativeimpact onburden ofdiseaseNo impact onburden ofdiseaseSmall positiveimpact onburden ofdiseaseModeratepositive impacton burden ofdiseaseSignificantpositive impacton burden ofdiseaseClientexperienceImpact on safety,effectiveness, and clientexperience of healthservice(s) provided.8 Negativeimpact (safetyor satisfaction)for more than20% ofaffected clientsNegativeimpact (safetyor satisfaction)for 10% to20% ofaffected clientsNegativeimpact (safetyor satisfaction)for 5% to 10%of affectedclientsLess than 5%of affectedclientsexperience anychanges insatisfaction ofsafetyPositive impact(safety orsatisfaction) for5% to 10% ofaffected clientsPositive impact(safety orsatisfaction) for10% to 20% ofaffected clientsPositive impact(safety orsatisfaction) formore than20% ofaffected clientsMittonetal.BMCHealthServicesResearch2011,11:169http://www.biomedcentral.com/1472-6963/11/169Page5of11Table 2 Criteria and rating scale* (Continued)WorkplaceenvironmentImpact on workplaceenvironment includingmorale, tools andequipment, personal andprofessional growth andteamwork5 Significantnegativeimpact onrecruitmentand retentionor on stressleaveModeratenegativeimpact onrecruitmentand retentionor on stressleaveSmall negativeimpact onrecruitmentand retentionor on stressleaveNo impact Small positiveimpact onrecruitmentand retentionor on stressleaveModeratepositive impacton recruitmentand retentionor on stressleaveSignificantpositive impacton recruitmentand retentionor on stressleaveOrganizationalImpact25 Innovation andknowledgetransferImpact on the generationand/or application ofnew knowledge/practice.5 Significantnegativeimpact on thegeneration orapplication ofnewknowledge/practiceModeratenegativeimpact on thegeneration orapplication ofnewknowledge/practiceSmall negativeimpact on thegeneration orapplication ofnewknowledge/practiceNo impact Small positiveimpact on thegeneration orapplication ofnewknowledge/practiceModeratepositive impacton thegeneration orapplication ofnewknowledge/practiceSignificantpositive impacton thegeneration orapplication ofnewknowledge/practiceImplementation Challenges to theimplementation ofproposed initiative (orreversal)5 Significantpoliticalresistance andchange wouldbe verydifficult toundoSignificantpoliticalresistance butchange couldbe undoneModeratepoliticalresistanceexpectedNo politicalimpactModeratepoliticalsupportexpectedStrong politicalsupportexpectedStrong politicalsupport andchange can bereversedDownstreamimpact onserviceutilizationImpact of the proposedchange on future use ofhealth care services10 Significantincrease infuture use ofhealth careservicesModerateincrease infuture use ofhealth careservicesSmall increasein future useof health careservicesNo impact onfuture use ofservicesSmall decreasein future useof health careservicesModeratedecrease infuture use ofhealth careservicesSignificantdecrease infuture use ofhealth careservices*This table describes the overall domain, criteria, brief definition of criteria, weighting of criteria and rating scale for assessing each proposal.Mittonetal.BMCHealthServicesResearch2011,11:169http://www.biomedcentral.com/1472-6963/11/169Page6of11moving forward, it was felt that two key aspects of thetraining should be emphasized: the use of real life exam-ples in demonstrating the potential impact of PBMAand establishing that PBMA is principally about changesto services at the margin.All respondents were extremely positive about frame-work implementation and resulting recommendations.There was recognition amongst respondents that therole of PBMA was primarily limited to the developmentof a plan to address the expected deficit. However, inthat light, PBMA was viewed as being more robust thenprevious resource allocation processes that relied on his-torical patterns and/or politics. This was largely due to awell-defined set of decision criteria and high degree ofprocess transparency. There was also clear recognitionof the potential value of developing investment propo-sals and of considering re-allocations beyond what wasrequired to balance the budget. Overall the results wereseen as an improvement from previous activity for twomain reasons: first, the marginal approach was seen tohave led in many cases to a different set of proposalsthan what would have been otherwise considered; andsecond, the process enabled consideration of realchanges to services instead of an ongoing search forgreater efficiency. Open consideration of changes to ser-vices created a new range of alternative proposals toaddress the deficit problem.A third major theme from the interviews related tofuture opportunities for the use of this priority settingprocess in the health authority. The clear message fromthe interviews was that PBMA is a desirable process andwider rollout should occur within VCH. This was basedon three main points. First, the process provides a mea-surement methodology for the management of resourcesthat was demonstrated to be effective in the VancouverCommunities pilot. Second, respondents felt that theprocess would lead to a more consistent approach toresource management across the entire organization.Third, because the process allows for marginal analysisacross disparate services, the process creates opportu-nities for sharing of knowledge across the organization.It was felt that the rating process, specifically, wouldprovide opportunities to exchange information betweenparts of the organization that do not tend to worktogether but whose decisions impact each other.DiscussionThe logic of PBMA is straightforward: when resourcesare limited, decision makers must look at ways to re-allocate within the fixed pot available in order to receivethe greatest return on investment. The PBMA processtends to bring a level of rigor and consistency to deci-sion making seldom found within a historical and/orpolitical allocation model [4]. The approach has beenimplemented in many organizations across countries [5],and where formal evaluation has taken place, decisionmakers almost universally indicate a desire to continueon with the process in future years subject to specificTable 3 Programs in scope of exerciseDirect Services In Scope Contracted Services In Scope Total In ScopePrevention and Promotion 18,964,284 50,296 19,014,580Primary CarePrimary Care 15,764,244 478,581 16,242,825Adults and Older Adults 32,729,138 22,347,397 55,076,536Alcohol and Drug 21,211,299 20,965,473 42,176,772Mental Health 39,290,286 44,729,076 84,019,362Special Care Contracts 2,153,626 2,153,626Total Health Serv. and Supplies 127,959,251 90,724,449 218,683,700Program Supports 18,173,063 0 18,173,063Total Van. Comm. Hlth Services 146,132,314 90,724,449 236,856,763Mitton et al. BMC Health Services Research 2011, 11:169http://www.biomedcentral.com/1472-6963/11/169Page 7 of 11Table 4 Disinvestment options by weighted scoreDisinvestment Opportunity Weighted Score* Annualized Savings** VCH FTE impacted1 0.44 $291,450 0.002 0.00 $76,690 -0.803 0.00 $42,686 -1.004 0.00 $182,439 0.005 0.00 $21,588 -0.506 0.00 $15,494 -0.407 0.00 $40,000 -0.608 0.00 $112,395 0.009 0.00 $17,741 -0.4410 0.00 $48,400 -0.5011 0.00 $50,700 -1.0012 0.00 $57,886 -1.0013 0.00 $77,000 -1.0014 -0.25 $119,224 -1.0015 -0.31 $48,215 -1.0016 -0.31 $53,956 -0.7017 -0.36 $120,000 -1.0018 -0.50 $53,723 -0.6019 -0.51 $42,000 -0.5020 -0.53 $28,523 -0.1621 -0.54 $100,906 -0.9022 -0.56 $50,729 -0.1023 -0.58 $96,498 -1.3024 -0.58 $240,630 -2.8025 -0.62 $762,715 -15.8026 -0.65 $87,635 -1.0027 -0.72 $64,340 -0.8028 -0.73 $41,461 -0.5029 -0.74 $41,897 -0.0930 -0.76 $295,679 0.0031 -0.83 $26,574 -0.3032 -0.86 $60,000 0.0033 -0.87 $88,776 0.0034 -0.92 $21,000 0.0035 -0.92 $70,605 -2.0036 -0.96 $23,094 0.0037 -1.00 $58,882 0.0038 -1.04 $397,352 0.0039 -1.04 $278,784 -4.0040 -1.14 $120,000 0.0041 -1.16 $68,000 0.0042 -1.41 $134,500 -2.8043 -1.45 $200,000 0.0044 -1.64 $82,000 0.00TOTAL $4,912,167 -44.59*A positive weighted score indicates that acting on the disinvestment would result in the organization moving closer to its objectives; zero weighted scoreindicates no impact on organizational objectives; a negative weighted score indicates that implementation would move the organization away from itsobjectives. **If all savings were realized as indicated, the deficit would be met by opportunity #42, leaving two proposals and approximately $282,000 forconsideration against the investment opportunities.Mitton et al. BMC Health Services Research 2011, 11:169http://www.biomedcentral.com/1472-6963/11/169Page 8 of 11refinement [6]. Such support from the end-users is likelydue at least in part to building in process characteristicssuch as transparency and use of best available evidence,both known to be key elements of fairness [7].In the case of VCH, PBMA was implemented in a sin-gle division with a focus on primary care, communitycare and public health. To our knowledge few PBMA stu-dies have been conducted in these areas. The primaryaim of the exercise was to bring expenditure in line withavailable funds. The decision to use PBMA and to focuson Vancouver Communities as a pilot was the sole dis-cretion of the Senior Executive of the health authority.As part of the PBMA process, decision makers mustdetermine what activities are ‘in scope’ and what are ‘outof scope’. In this case a little over half the VancouverCommunities budget was deemed to be out of scope fora variety of reasons including that some programs werering-fenced, some programs received direct Ministry ofHealth funds and thus could not be challenged in thisprocess, and in some cases programs were undergoingother separate reviews to address their deficit challenges.It was the working committee comprised of VancouverCommunities personnel that provided the recommenda-tion for what was in and out of scope, and the deficit tar-get was set accordingly. Some early discussion centeredon the difficulties of making decisions in community ser-vices without acute services being represented at thetable. Being explicit about this ensured that as proposalscame forward, appropriate discussion with acute-basedcounterparts took place and generally it was felt that‘cost-shifts’ from one part of the organization to anotherwere avoided. Overall the process was viewed favorablyby the end-users and the primary objective was met.Nonetheless, one might anticipate at least three chal-lenges to what was done with PBMA at VCH. First, asthe timeline was very tight, proposal development maynot have been as evidence based as one would hope.This was likely the case, although the application was atthe level of managers and directors who have intimateknowledge of the programs under consideration. Theleap was in drawing on evidence to support proposalsfor changes to existing services and as would beexpected in some cases research evidence was availableand in other cases ‘softer’ forms of evidence were reliedupon. As reasonable evidence is a contributor to processfairness, one could argue that this process was not asfair as might be the case had longer timelines be in playand a stronger evidence base was sought. Ideally, man-agers and clinical leaders would receive support (eitherexternal from university-based researchers or internalfrom decision support personnel) to review the range ofevidence for any given proposal in as thorough a man-ner as is possible given limited resources and time. Sec-ond, PBMA may not have lived up to its name becausea formal re-allocation exercise did not immediately fol-low the allocation of agreed disinvestment proposals tothe deficit. However, while the goal of PBMA is alwaysto go deeper into the margin to elicit options for relativevalue assessment, it would not be correct to suggest thatre-allocation did not occur in VCH. Disinvestment pro-posals were acted upon, with the released resourcesshifted to the corporate bottom line. That is, the oppor-tunity cost of the disinvestments were assessed and itwas felt that the benefit gain of these programs could beforegone in view of meeting the organization’s budgetrequirements. In addition, all stakeholders expressed adesire to move forward with comparing the investmentoptions to remaining (and perhaps additional) disinvest-ment options once the dust had settled. Third, it is notpossible to know if the ‘right’ decisions were made withrespect to disinvestment. Clearly the decision makersfelt that better decisions were made then had the pro-cess not been used, but this is only a proxy of the trueimpact. In the absence of a real-world control, whichwould unlikely be plausible, one cannot be sure thatwhat was done was right. Simply put, this is the realityof uncertainty in health care decision-making.More generally, despite success across different set-tings, it is clear that the biggest stumbling block ofPBMA is that which is at the very essence of choicemaking in health care: how to identify disinvestmentsalongside options for investment [3]. In this, PBMAstands no different then any other resource managementtool. In order for ‘success’ to be achieved, decisionmakers must be ‘bought in’ to acceptance of scarcityand the need to assess options for change, there mustbe strong leadership, and a high level of trust must existbetween managers and clinicians. These are but a fewkey organizational attributes found in the literature thatTable 5 Investment options by weighted scoreInvestmentOpportunity*WeightedScore**AnnualizedInvestment***1 2.07 $95,0002 1.87 $69,6003 1.72 $10,0004 1.43 $45,0005 0.44 $310,000TOTAL $529,600*These proposals were put forward for consideration but were not acted uponimmediately.**Higher weighted scores indicate greater benefit gain by acting on theinvestment opportunity.***If marginal analysis was to proceed beyond deficit elimination, re-allocationfrom disinvestment 43 to investments 1 to 3 would be recommended, as thebenefit loss on the disinvestment is less then the potential benefit gainedthrough these investments. Investment opportunity 4 and 5 would notproceed as the expected benefit gain is less then the benefit loss ofdisinvestment 44.Mitton et al. BMC Health Services Research 2011, 11:169http://www.biomedcentral.com/1472-6963/11/169Page 9 of 11can help envisage the outcome of a given priority settingexercise. But is that enough? Is it the case that an exter-nal impetus such as a projected deficit is required inorder to achieve disinvestment targets?For the exercise reported herein, the primary aim wasto implement a more rigorous, criteria-based process toachieve a disinvestment target based on a projected defi-cit for the Vancouver Communities division. Thus suc-cess in this project can be measured against nothing lessthen whether this was achieved. That the working groupwent further to produce more disinvestment optionsthen the deficit called for perhaps suggests that the deci-sion makers had bought in to the principle of PBMA asa re-allocation tool. Those interviewed suggested thatapproaching programs for disinvestment at the marginresulted in a different set of options then would haveresulted through standard program evaluation (andundoubtedly different then across the board percentagecuts). So while there was pain in the cuts, it was collec-tively held that what was put forward was the least pain-ful set of options (as measured against the objectives ofthe organization which were reflected in the criteria). Atthe same time, there can be no denying that the externalfiscal impetus ‘forced their hand’. It seems that the deci-sion makers got to a different place then they wouldhave had they not implemented PBMA but it is notclear that the decision makers would have engaged in anew method of priority setting had there not been anexternal impetus. In VCH, deficits had been projected inprevious years but the difference this year, it wouldseem, was a clear government directive of no bailouts.So strictly speaking it was not just the external impetusof a fiscal constraint but the external political will to not‘allow’ deficits to stand, which was very different thenprevious years.Importantly, regardless of the fiscal driver, the ‘sellingpoint’ of PBMA must remain as a process that canguide decision making towards optimal allocation oflimited resources. Put another way, proactive resourcemanagement requires continual assessment of existingservices vis-à-vis new investment options and where therelative value of the latter outweighs the formerresources should be shifted accordingly [8]. This is thecase whether there is a deficit, a surplus, or the organi-zation is in a neutral budget state. This is also the casewhether PBMA is being considered or some other fra-mework or process is taken up to assist decision makersin resource allocation. Thus in response to the abovequestion, based on our own experience and what isreported in the literature, our view is that it is notnecessary to have an external fiscal driver in play but atthe same time it can serve as a very helpful lever.One question for VCH is how to proceed so that thesuccess within Vancouver Communities can be builtupon in other areas while also mitigating potential chal-lenges. In our view, major gains in terms of shiftingresources to better meet organizational objectives is bestachieved through systematic application of the frame-work across divisions. In that, several points should beconsidered. First, the willingness of decision-makers toparticipate depends on their trust in the process. If theonly perceived outcome is a likely loss of resources,decision-makers may be reticent to participate and noprocess can overcome a ‘forced participation’. Thisrelates to what Jan calls ‘credible commitment’ [9]. Sec-ond, as the use of PBMA widens, more disparate ser-vices will be included in the process (eventuallyincluding a mix of acute care and population health ser-vices). As others have found, this is the real raison d’etreof multi-criteria decision analysis as it provides amethod of assessment that relates to the many different(and at times competing) objectives of the decisionmaker [10]. Finally, there is always a risk of over reli-ance on the actual rating score for each proposal. Theassessments that lead to these ratings, and the underly-ing assumptions, should always be critically analyzed. Aswas done in the exercise described herein, the quantita-tive assessment can serve as the basis for consensusdecision-making.A final thought for further rollout within VCH is tohighlight the importance of the sequential buy-in thattook place in the Vancouver Communities exercise.Because the training was viewed favorably there wasearly buy-in for the process. Then, because of broadparticipation in criteria development, there was buy-infor the notion of how ‘benefit’ would be defined. Next,there was buy-in into the marginal approach to proposaldevelopment and assessment. And finally, building onthe previous steps, there was buy-in into the rating ofproposals as well as the final rankings. In the end, thisled to a plan that had consensus approval of the work-ing committee. Engagement by the Advisory Panel earlyon and throughout the process ensured that there wereno surprises at that level. In addition, the AdvisoryPanel took its role seriously and was able to provide astrategic lens that complemented the operational lens ofthe working committee. In short, buy-in and buildingfrom within can be seen as key strategies for further useof PBMA in VCH and elsewhere.ConclusionIn the end, the potential of moving to an organization-wide application of PBMA in VCH will hinge mostdirectly on the broader organizational context (e.g., doesit have a ‘learning culture’), as well as executive endorse-ment and clinical leadership. In this, if the focus is sim-ply to meet a projected deficit based on explicit criteria,the PBMA process is being sold well short. That PBMAMitton et al. BMC Health Services Research 2011, 11:169http://www.biomedcentral.com/1472-6963/11/169Page 10 of 11can respond should this be the objective was clearlydemonstrated in the Vancouver Communities exercise.Case studies both in Canada and elsewhere havedemonstrated success in terms of identifying disinvest-ment options sufficient to meet a budget gap and alsoenable assessment for resource re-allocation across ser-vices. Some stakeholders may view this through the lensof ‘winners’ and ‘losers’ but the process should focus onthe net impact, in terms of ability to meet system objec-tives, for the entire population being served. It is withthis in mind, regardless of the fiscal reality of the day,that will place decision makers in a position to take upa framework like PBMA to improve resource manage-ment activities.AcknowledgementsWe would like to acknowledge the members of the priority setting workingcommittee in the Vancouver Communities division of Vancouver CoastalHealth as well as the members of the priority setting advisory panel thatworked on this project. This project was funded by Vancouver CoastalHealth. Craig Mitton receives funding from the Michael Smith Foundationfor Health Research and Francois Dionne was funded through a CanadianInstitutes for Health Research Graduate Studentship.Author details1Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal HealthResearch Institute, Vancouver, Canada. 2School of Population and PublicHealth, University of British Columbia, Vancouver, Canada. 3VancouverCoastal Health, Vancouver, Canada.Authors’ contributionsCM and FD drafted the paper and participated in study design. RD, DC andSB participated in study design and provided detailed comments on thepaper. The authors read and approved the final manuscript.Competing interestsThe authors declare that there are no competing interests.Received: 28 September 2010 Accepted: 14 July 2011Published: 14 July 2011References1. Pearson S, Littlejohns P: Reallocating resources: How should the NationalInstitute for Health and Clinical Excellence guide disinvestment efforts inthe National Health Service? J Health Serv Res Policy 2007, 12:160-65.2. Elshaug AG, Moss JR, Littlejohns P, Karnon J, Merlin TL, Hiller JE: Identifyingexisting health care services that do not provide value for money. Med JAust 2009, 90(5):269-73.3. Mitton C, Donaldson C: The Priority Setting Toolkit: A Guide to the Use ofEconomics in health Care Decision Making. London: BMJ Books; 2004.4. Peacock S, Ruta D, Mitton C, Donaldson C, Bate A, Murtagh M: Usingeconomics for pragmatic and ethical priority setting: two checklists fordoctors and managers. BMJ 2006, 332:482-85.5. Mitton C, Donaldson C: Twenty-five years of program budgeting andmarginal analysis in the health sector, 1974-99. J Health Serv Res Policy2001, 6(4):239-48.6. Haas M, Viney R, Kristensen E, Pain C, Foulds K: Using programmebudgeting and marginal analysis to assist population based strategicplanning for coronary heart disease. Health Policy 2001, 55(3):173-86.7. Gibson JL, Mitton C, Martin DK, Donaldson C, Singer PA, Ethics &economics: Does program budgeting and marginal analysis contributeto fair priority setting? J Health Ser Res Policy 2006, 11(1):32-7.8. Donaldson C, Bate A, Mitton C, Dionne F, Ruta D: Rational Disinvestment.QJM 2010, 103(10):801-807.9. Jan S: A perspective on the analysis of credible commitment andmyopia in health sector decision making. Health Policy 2003, 63(3):269-78.10. Baltussen R, Youngkong S, Paolucci F, Niessen L: Multi-criteria decisionanalysis to prioritize health interventions: Capitalizing on firstexperiences. Health Policy 2010, 96(3):262-4.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/169/prepubdoi:10.1186/1472-6963-11-169Cite this article as: Mitton et al.: Difficult decisions in times ofconstraint: Criteria based Resource Allocation in the Vancouver CoastalHealth Authority. BMC Health Services Research 2011 11:169.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMitton et al. BMC Health Services Research 2011, 11:169http://www.biomedcentral.com/1472-6963/11/169Page 11 of 11

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