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Decision maker views on priority setting in the Vancouver Island Health Authority Dionne, Francois; Mitton, Craig; Smith, Neale; Donaldson, Cam Jul 21, 2008

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ralCost Effectiveness and Resource ssBioMed CentAllocationOpen AcceResearchDecision maker views on priority setting in the Vancouver Island Health AuthorityFrancois Dionne1, Craig Mitton*2,3,5, Neale Smith2 and Cam Donaldson4Address: 1Department of Health Care and Epidemiology, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada, 2Health Studies, University of British Columbia Okanagan, 3333 University Way, Kelowna, BC, V1V 1V7, Canada, 3Child and Family Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada, 4Institute of Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK and 5Health Studies, Faculty of Health and Social Development, University of British Columbia Okanagan, 3333 University Way, Kelowna, BC, V1V 1V7, CanadaEmail: Francois Dionne - fdionne@telus.net; Craig Mitton* - craig.mitton@ubc.ca; Neale Smith - neale.smith@ubc.ca; Cam Donaldson - cam.donaldson@ncl.ac.uk* Corresponding author    AbstractBackground: Decisions regarding the allocation of available resources are a source of growingdissatisfaction for healthcare decision-makers. This dissatisfaction has led to increased interest inresearch on evidence-based resource allocation processes. An emerging area of interest has beenthe empirical analysis of the characteristics of existing and desired priority setting processes fromthe perspective of decision-makers.Methods: We conducted in-depth, face-to-face interviews with 18 senior managers and medicaldirectors with the Vancouver Island Health Authority, an integrated health care provider in BritishColumbia responsible for a population of approximately 730,000. Interviews were transcribed andcontent-analyzed, and major themes and sub-themes were identified and reported.Results: Respondents identified nine key features of a desirable priority setting process: inclusionof baseline assessment, use of best evidence, clarity, consistency, clear and measurable criteria,dissemination of information, fair representation, alignment with the strategic direction andevaluation of results. Existing priority setting processes were found to be lacking on most of thesedesired features. In addition, respondents identified and explicated several factors that influenceresource allocation, including political considerations and organizational culture and capacity.Conclusion: This study makes a contribution to a growing body of knowledge which provides thetype of contextual evidence that is required if priority setting processes are to be used successfullyby health care decision-makers.BackgroundDespite the fact that most hospital and physician servicesare publicly funded in Canada (Canadian Medicare coversther, given that there are very few constraints on thegrowth of demand for these services [1], it is not surpris-ing to find that, in a context where governments arePublished: 21 July 2008Cost Effectiveness and Resource Allocation 2008, 6:13 doi:10.1186/1478-7547-6-13Received: 9 August 2007Accepted: 21 July 2008This article is available from: http://www.resource-allocation.com/content/6/1/13© 2008 Dionne 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 8(page number not for citation purposes)about 98% of hospital and physician costs), there are lim-its to the resources available to pay for these services. Fur-focused on cutting taxes, decisions regarding the alloca-tion of the available resources are a subject of growingCost Effectiveness and Resource Allocation 2008, 6:13 http://www.resource-allocation.com/content/6/1/13conflict, and a growing source of dissatisfaction for deci-sion-makers [2].In most health care organizations, resource allocationdecisions are typically based on historical spending pat-terns, adjusted through targeted budget increases relatedto political and demographic influences [2]. This meansthat gaps in service availability can only be addressedthrough increases in the organization's funding orthrough cost minimization strategies (to free up somemoney). Dissatisfaction with the results of historical allo-cation patterns have led to an increased interest inresearch on more explicit, evidence-based resource alloca-tion processes in health care [3]. An emerging area withinthis research has been the empirical analysis of the charac-teristics of existing and desired priority setting processes,as well as the structural features of health care organiza-tions that hinder the implementation of desired processes[4], from the perspective of decision-makers. The goal is todescribe what health care decision-makers want in a prior-ity setting process and what they see as barriers to imple-menting such processes.This paper presents information obtained through inter-views of decision makers in the Vancouver Island HealthAuthority (VIHA), one of six health authorities in BritishColumbia, Canada. This study was the first step in aresearch project aimed at transforming the priority settingpractices within VIHA towards a more formal, evidence-based process (known as program budgeting and mar-ginal analysis, or PBMA).The primary objectives of this study were to develop anunderstanding of the characteristics of historical resourceallocation practices, to determine what institutional fea-tures shaped these practices and to identify desiredimprovements from the perspective of decision-makers inan organization committed to the implementation of aformal priority setting process. Specifically, this studyasked decision-makers in a regional health authority todescribe the features of their ideal priority setting processand to assess current practices against this standard. Theorientation of this paper is towards the operationalizationof a formal priority setting framework, not merely justifi-cation for implementation of such a framework.There is a growing body of knowledge on decision-mak-ers' perspective on priority setting and resource allocationprocesses but it includes very limited information fromdecision-makers in integrated health care organizationswhere a formal priority setting process is actually beingimplemented. Greener and Powell [5], for example, sur-veyed senior decision-makers in the 121 health authori-respondents used formal priority setting processes whileothers did not, but results are not differentiated betweenthose two groups making it impossible to measure theassociation between the use of formal priority settingprocesses and satisfaction with resource allocation deci-sions made. Their overall conclusion was that, despite anexplicit desire from Government to have health authori-ties adopt an evidence-based resource allocation process,very slow progress has been made in that direction. Thetwo main reasons cited for this are: 1) cynicism on the partof the health authorities with constantly changing Gov-ernment plans; and 2) a path-dependent budget makingprocess (a process that reinforces historical patterns)which only permits changes at the margins.Mitton and Prout [6] surveyed decision-makers of aregional health care organization in Australia that wasconsidering implementing a formal priority setting proc-ess. They found strong support for moving toward such aprocess. The main desired features of the process were acommitment from the Government to follow-throughwith full implementation and acceptance of the results,and means to improve intra-organizational coordination.Challenges identified included concerns over the system-wide impact of a priority setting process, particularly interms of its effect on small towns, political interference,and organizational dynamics (e.g., level of trust withinthe organization). This health care organization did notadopt a formal priority setting process.Martin et al [7] interviewed members of two committeescharged with priority setting for disease-specific new tech-nologies in Ontario, and focused on the perceived fairnessof their processes. They found the extent to which stake-holders' perspectives are included in the process to be akey determinant of perceived fairness. Most respondentsstated that fairness depends on the inclusion of the per-spectives of all parties affected and in a way that is honestand understandable by all. Other determinants of fairnesswere identified as consensus decision-making and trans-parency of the process.Jan [8] approached the question of what decision-makerswant in a priority setting process from a theoretical per-spective by discussing the impact of institutional contexton the success of a priority setting process. His primaryassertion was that a typical priority setting frameworkrelies heavily on "the goodwill of participants in provid-ing realistic assessment of expected benefits" [[8], p.633]in order to collectively achieve "efficiency gains" (p.634).Attaining the goodwill required to achieve collective gainsdepends on the strength of the link between collectivegains and individual interest. The weaker this link, thePage 2 of 8(page number not for citation purposes)ties in England and Wales to examine approaches topriority setting and resource allocation. Some of thegreater the incentive for 'gaming' the process, which,added to the incomplete information available on bene-Cost Effectiveness and Resource Allocation 2008, 6:13 http://www.resource-allocation.com/content/6/1/13fits and costs, leads to significant limitations to the poten-tial benefits of priority setting processes. Jan proposesthree main solutions: 1) increasing the information onprogram costs and benefits in the organization; 2) limit-ing the number of alternatives considered in a priority set-ting exercise and 3) ensuring long-term commitment tothe organization from the decision-makers (through con-tracts) so that they see their forecasts through.It is clear that a thorough understanding of current prior-ity setting/resource allocation practices, what shapes thesepractices, and what decision-makers see as key areas forimprovement, are essential pieces of information in thedevelopment of a well-designed resource allocation proc-ess. Such information can also provide a roadmap to thisprocess where anticipated barriers are identified. It is alsoclear that a study of decision-makers in an integratedhealth care organization that is implementing a formalpriority setting process will fill a gap in the spectrum ofexisting studies.MethodsContextThe Vancouver Island Health Authority (VIHA) is respon-sible for the provision of health care services to a popula-tion of about 730,000 people in a mix of urban and ruralenvironments. This health authority has approximately16,000 employees, operates 15 acute care hospitals, isserved by about 1,600 physicians, and has an annualoperating budget of $1.4 billion CAN (2007). At the timeof the interviews (Fall 2005), and continuing since then,VIHA has been involved in an organizational re-structur-ing with the objective of creating an integrated organiza-tion providing services across the full continuum of care.Key features of the new organizational model are co-man-agement of clinical portfolios (administrative and medi-cal directors) and devolution of decision-making closer tothe front line (i.e., matching authority to responsibility).The re-design of the priority setting practices was seen bythe CEO and the 10 member Executive team as part of thisorganizational re-structuring.Design and analysisIn-depth, face-to-face interviews were conducted with 18senior managers and medical directors within VIHA in theFall 2005 (the questionnaire is attached as Appendix A).Respondents were purposively selected to achieve a heter-ogeneous sample, including a breadth of priority settingexperience and roles in the health authority [9]. Approxi-mately one quarter of respondents were physicians whilethe others were professional managers/administrators,although some of those would have a clinical back-ground. The questionnaire was developed based on previ-questions were open-ended while others asked for therespondents' perception in relation to a set of specificprocess evaluation criteria such as: fairness, informationdissemination, use of research evidence, appeal process,and stakeholder representation.Interviews were recorded and then transcribed. A researchteam member analyzed the contents of the transcriptsusing the N*6 qualitative analysis software package.Major themes and sub-themes were developed until theo-retical saturation was reached and no new themes wereidentified [10,11]. The code structure was refined until thethemes, or categories of meaning, had internal conver-gence and external divergence (i.e., the categories wereinternally consistent but distinct from one another) [12].A second research team member independently coded asample of the transcripts to ensure that consistent patternsof information emerged. The study was approved by theBehavioral Research Ethics Board at the University of Brit-ish Columbia.ResultsThis section focuses on two main areas of findings fromthe interviews. First, we indicate the characteristics whichrespondents identify as desirable in a resource allocationprocess – identified either directly or by comparison withtheir experience in previous priority setting efforts. Sec-ond, we describe a number of factors, identified by therespondents, which determine or shape the prospects forformalized resource allocation activity.Characteristics of existing and desired resource allocation processesThrough the interviews a set of nine features describingthe desired resource allocation process at VIHA emerged.In this sub-section, we define these features and use themas criteria against which the past priority setting practicescan be evaluated.The first desired feature is baseline assessment, or the inclu-sion in the priority setting process of existing activities sothat an appropriate level of funding for these activities canbe determined. Overall, respondents felt that baselineassessment was lacking in past priority setting processes:"we assume when a new program comes into play... thatthe baseline is correct. And I think there should be areview on the front end to ascertain whether the baselinesare in fact correct. And I think that that's a gap in this proc-ess".The second feature is the use of best evidence embedded inthe workings of the process. There are currently mixedopinions as to whether the past processes delivered onPage 3 of 8(page number not for citation purposes)ous experience elsewhere [6] and was further informedthrough an updated review of the literature. Some of thethis criterion. For example, one respondent stated, "Yeah,I would think we've tried to be evidence-based as much asCost Effectiveness and Resource Allocation 2008, 6:13 http://www.resource-allocation.com/content/6/1/13possible", while another argued that "I think it's beenhaphazard and ad hoc".The third feature is clarity, meaning a process that is clear,explicit and transparent. The respondents suggested thatpast processes failed on this criterion, although somerespondents expressed the view that the potential for clar-ity exists. Responses ranged from: "I would say the actualprocess or processes are probably, generally speaking, nottoo explicit" and " There have been things approved andwe've heard about it through the grapevine and it hasn'tbeen transparent" to "Fairly constant methodology usedactually... very, very focused and clear leadership-that'sfundamental, right? So to me it looks like the process haspotential".The fourth feature is consistency referring to a process thatis applied uniformly across the organization and survivesover time. The processes employed prior to Fall 2005 werejudged to be lacking on this criterion: "We've had multipleprocesses, multiple criteria, multiple rationales andchanges in decision makers over the last five to ten years"and "It hasn't been consistent... you do seem to have thesedouble standards".The fifth desired feature is quality criteria, defined as deci-sion criteria that are clear, measurable and relevant to theorganization. Consensus opinion on the performance ofpast processes in regard to this criterion was negative. Cri-teria were found to be lacking clarity, ability to discernbetween proposals and consistency. For example, onerespondent stated: "The evidence was always there... butthere was no criteria to say whose (department) was themost needy".Dissemination is the sixth feature. It refers to the built-incommunication and explanation, throughout the organi-zation, of all aspects of the process, including decision cri-teria, actual decisions and rationales. Performance of pastprocesses in terms of this criterion was rated as mixed inrelation to internal stakeholders and lacking with respectto external stakeholders. With internal stakeholders, com-munication efforts were found to be insufficient by manyrespondents while some judged these efforts to be suffi-cient. Opinions ranged from: (in assessing communica-tion efforts) "I don't think we have in the past done wellat that and even last year. I don't think we did as well aswe could have" and " Communicating with our care pro-viders and our middle management and our staff aboutwhy certain decisions around priorities have been madeprobably hasn't occurred at a detailed level very well" to(in answering the same question) "I would have to say...that the answer is yes... they do a very good job of tellingthey made and what to do if you felt that there was a needto respond to an appeal around that".The seventh feature is evaluation; the process should havea built-in evaluation component that would ensure ongo-ing documentation of the activities and assessment of theimpact of the resulting budget decisions. This feature didnot exist in priority setting processes prior to the Fall2005.The eight feature of desired priority setting processes isappropriate stakeholder representation. Just like dissemina-tion, representation is broken down into internal and exter-nal stakeholders. On both fronts, opinions were mixed onthe performance of past processes. With regard to internalstakeholders: "It seems to that what I've seen mostrecently in the organization is (more of a collaborativeprocess at the middle management level) with some inputfrom providers or from people who are close to the actionwithin each programs...and then of course, a lens appliedby more senior people to that prioritization" and "it justdidn't lead to a feeling that people had had input and anopportunity to advocate for what they thought was impor-tant perhaps as well as it could have". As for external stake-holders, i.e. the public: "I do know that the... public inputis brought to processes or brought to decisions that comefrom the program areas, so wherever there are AdvisoryCommittees, or Councils, or whatever within the pro-gram, that information does help to inform the program,where they get their priorities" and "I can't recall off thetop of my head any specific examples of the public beingactively involved in any priority setting."Finally, the ninth feature is a link to the strategic directionof the organization. The priority setting process shouldclearly reflect, in all its operations, the strategic directionestablished for the organization. According to those inter-viewed, this linkage was limited in past processes.Determinants and challengesRespondents identified several factors that influence ordetermine the shape of the resource allocation process, i.e.factors that can help explain the divergence between exist-ing and desired processes. These factors can be classifiedunder two main themes: political considerations andorganizational culture and capacity.Respondents thought that political forces often directlyshaped the allocation decisions. The most important ofthese political forces was seen to be the provincial Minis-try of Health. "Health care is a huge political issue and thereality of that is that governments who fund the healthauthorities get caught up in the decisions of the healthPage 4 of 8(page number not for citation purposes)us what we hope to do, why they made the decisions that authorities and it becomes political" – overriding otherCost Effectiveness and Resource Allocation 2008, 6:13 http://www.resource-allocation.com/content/6/1/13factors that might be considered during formal prioritysetting activities.Political decisions have also resulted in repeated andextensive restructuring of VIHA in recent years. Thisorganizational change has, at a minimum, hampered thedevelopment of a stable system of priority setting. Thishas affected negatively VIHA's performance in areas suchas the consistency of resource allocation choices throughtime, across departments and among different stakehold-ers, and the dissemination of information about the proc-ess and the decision criteria. The instability has also heldback efforts to create shared vision, goals, and strategicdirections on an organization-wide basis.Also, political decisions, related primarily to a focus on taxcuts, have made resources very tight. An environment offiscal constraint has enveloped VIHA since its establish-ment. This has shaped the organization's culture and hasbeen internalized by the decision makers. It is reflected ina lack of interest by some in formal mechanisms for prior-itization; according to one respondent, "we didn't need aformalized process for investing a lot of money becausewe didn't have a lot of money to invest". In VIHA, accord-ing to another, "we come from a scarcity mentality...where you protect your resources... you don't share thoseresources. And I think that's a challenge".The other category of determinants and challenges is theorganizational culture and capacity. One important waythe organizational culture affects the priority setting proc-ess is through the development of a shared visionthroughout the organization. Resource allocation in anintegrated health system like VIHA can occur within port-folios (defined as a group of related programs, for exam-ple diagnostic and surgical services) or across portfolios;that is, the scope of prioritization can be relatively narrowor more broadly defined. Many felt the latter was mostdesirable: "isn't a bed replacement plan equally importantas diagnostic equipment which is just as important assome of the other things"? However, to carry out realloca-tions across portfolios, values related to different parts ofthe organization, providing different types of services,must be ranked so that the relative merit of any given pro-posal can be assessed. "One of the complexities of life inhealth authorities is the relationship between life anddeath services and residential services and palliative serv-ices and prevention services". Most of the respondentsthought that the values from the different parts of VIHAhave not been integrated into a cohesive shared visionthat would support such an undertaking. This integrationwas seen as likely to be a difficult task: "Care and compas-sion, client-focus, healthy workplace... all those kinds ofting agenda. I would like to see them articulated moreclearly, maybe more measurably."The scarcity mentality, the lack of experience workingtogether, and the lack of shared vision may all contributeto the fears expressed by some respondents that it mightprove impossible to establish a fair priority setting processacross the portfolio boundaries of VIHA: "life-saving pri-orities would always be ranked higher than rehabilitationpriorities".Finally, respondents expressed concerns over the organi-zational capacity in terms of time and skills required toimplement a resource allocation process and operational-ize it: "it's not that there isn't a lot of motivation to do evi-dence-based policy or budgeting decisions but thecapacity is limited around the resource and skills and timeand the tools that the decision-makers have to have to dothat". Organizational capacity as it relates to the informa-tion requirements of a priority setting process is anotherchallenge: "I think a large barrier to allocating resourceswhether it was in the past or now is good information, ishaving really good systems that allow us to get informa-tion that truly can inform us".DiscussionUnder the leadership of senior management, VIHA hasundergone a fundamental restructuring over the last threeyears. One of the areas specifically addressed in this re-structuring is the priority setting/resource allocation proc-ess. In our interviews, we asked decision makers at VIHAto reflect upon their previous approaches to priority set-ting and to identify features that would characterize animproved or ideal model. Our purpose was to explorehow decision-makers assess past priority setting processesby comparing them to their self-described ideal process.This investigation has produced information on thoseareas of priority setting processes where the greatest needfor/prospect of improvements exist, and therefore on thecriteria against which the value of any new process is mostlikely to be judged. We also uncovered a range of determi-nants and challenges that will influence an organization'sability to move toward this desired future.This information has implications for both researchersand decision-makers. For researchers, it provides directionfor future refinements to priority setting implementationprocedures. For decision-makers, it presents a checklistagainst which current practices can be assessed and short-comings identified.Several features of priority setting processes that emergedfrom our interviews are in line with previous researchPage 5 of 8(page number not for citation purposes)things are not always front and center on that priority set- findings. This was due in part to the fact that respondentswere probed on features that we specifically extractedCost Effectiveness and Resource Allocation 2008, 6:13 http://www.resource-allocation.com/content/6/1/13from the literature (e.g. features related to ethical consid-erations, such as those contained in the Accountability forReasonableness framework [13]). Our paper builds onprevious work in Canada and confirms previous findings.For example, Mitton and Donaldson [14] listed a numberof desired features of priority setting processes including:physician buy-in, transparency, stakeholder engagement,strategic links, and greater accountability. All of these werehighlighted in our study. Similarly, Teng et al. [15] alsolisted desired improvements in priority setting such as:transparency, defensibility, consistency and fairness.However, the current paper goes further in defining thedesired characteristics of priority setting processes. Forinstance, defining goals and outcomes for the process hadbeen identified as desirable in both previous studies inWestern Canada. Our study provides further clarityregarding the nature of those goals, specifically a desire touse priority setting processes to review baseline spendingi.e. not just to guide new spending. Another example isthe issue of decision criteria. Elsewhere decision-makersdiscussed a process that is explicit, that is linked to strate-gic direction and that is transparent. Our current work haslinked these characteristics directly to the decision criteriathat are used in the process. Here we found that decision-makers need to define criteria that are clear and measura-ble. Implications of this are that: 1) implementation pro-cedures should include a more detailed definition of thecharacteristics of decision criteria to be used; and 2) whendecision makers assess their current practices, their reviewof decision criteria should go beyond the fit with strategicdirections.In terms of international comparisons, determinants andchallenges to the priority setting process identified byrespondents in VIHA are in line with what was describedby Greener and Powell [5] based on work in the UK. Sim-ilarly, in work from Australia, Mitton and Prout [6] referspecifically to the influence of political considerations onpriority setting processes. Furthermore, organizationalcapacity and culture was raised by Jan [8] as a criticaldeterminant of the success of a priority setting process.Our study provides further illustrations of how thesedeterminants and challenges can manifest themselves inthe implementation of a formal priority setting process inan integrated health care organization.Finally, our findings support those of Bate et al [16] whoexamined how prioritization decisions are understoodand managed by decision-makers in the National HealthService (NHS) in England. Their conclusion was that"Commissioning as undertaken in practice, deviates fromwhat can be surmised from the guiding principles initiallydecision-makers in England, just as on Vancouver Island,know what they would like to do in terms of priority set-ting but in practice are far from their goal. Not surpris-ingly, this results in decisions that are not satisfying tothem.The main limitation of the current study is the fact thatrespondents were aware that these interviews were to pro-vide a baseline in a project that introduces a new prioritysetting process. Knowing that the Executive team hadalready decided to change the existing process as part ofthe corporate restructuring might have influenced theresponses; on the one hand, some respondents might belooking for ways to justify the decision to make thechange while on the other hand some might feel more freeto be honest given that they would not be stuck with aprocess they criticized. It is difficult to know which ofthese influences is present, and to what extent. Further-more, as data collection and data analysis did not takeplace concurrently, it was not possible to refine the inter-view guide in response to data as the study progressed.ConclusionAs the focus on resource allocation decisions in healthcaresharpens, the dissatisfaction of decision-makers with pre-vailing priority setting processes, mostly based on histori-cal patterns, is rising. In response, research on alternativesto existing processes is gathering increasing interest. Forthis research to provide workable solutions, it needs to becontextualized, as Lomas et al explain [[17], p.3]: "evi-dence has little meaning or importance for decision-mak-ing unless it is adapted to the circumstances of itsapplication. ... Scientific evidence on what works shouldbe combined with scientific evidence on context."In this study, we have summarized the views of decision-makers at VIHA regarding their past experience with andtheir hopes for priority setting processes. To date, littleresearch on the perspectives of decision-makers in inte-grated health care organizations on priority setting frame-works has been done. This study makes a contribution tothe growing body of knowledge on decision-makers' per-spective on priority setting processes which is the type ofcontextual evidence that is required if these processes areto be used successfully by health care decision-makers.Our findings confirm that decision-makers understandthe value of formal priority setting processes and a cleardescription of what they would like such processes to looklike is emerging. The next step is implementation of thisknowledge, which will require explicit handling of theidentified challenges. The fact that this knowledge isgrounded in the reality of the decision-makers' everydayPage 6 of 8(page number not for citation purposes)outlined by decision-makers and consequently performspoorly in relation to these" [[17], p.10]. In other words,life provides a solid base to work from.Cost Effectiveness and Resource Allocation 2008, 6:13 http://www.resource-allocation.com/content/6/1/13Competing interestsThe authors declare that they have no competing interests.Authors' contributionsFD drafted the manuscript. CM advised on the interviewplan, including formulation of the questionnaire, pro-vided direction for the drafting of the manuscript and sug-gested revisions to the manuscript. NS assisted with thethematic analysis of the interviews and contributed to thedrafting of the manuscript. CD provided significant com-ments on the content and the organization of the manu-script. All authors read and approved the finalmanuscript.Appendix AQuestions for one-on-one interviews with VancouverIsland Health Authority decision-makers on past, presentand future priority setting processes1 Can you please describe the process or processes thathave been used in the past to identify priorities and allo-cate resources across major program areas within the Van-couver Island Health Authority (VIHA)?2 Overall, do you think the process or processes employedin the past have worked well? How would you define 'suc-cess' in this instance?3 What specific barriers have been faced in the past whensetting priorities and allocating resources?4 Overall, how fair do you think the process (or processes)have been?4a How well have the process, decision criteria, andrationale on which decisions have been based been dis-seminated within or outside the organization?4b In your view, have decisions been made that are basedon the best available evidence, and in essence would bedeemed to be 'reasonable' by fair minded parties?4c Has there been an explicit process for appealingresource allocation decisions once made?4d To your knowledge, has the organization dedicatedresources to ensuring that the process and decisions areadequately communicated, that the decisions are basedon reasonable evidence and that an appeals process hasbeen developed?5 How could the past processes of setting priorities andallocating resources be improved? Please be as specific as6 What factors do you think are necessary for sustainingan explicit, formal, priority setting process in VIHA?Please be as specific as possible.7 How has the public been used in priority setting/resource allocation processes in the past? How would youwant the public to be involved in the priority setting proc-ess?8 What role have physicians played in priority setting/resource allocation processes in the past? How would youwant the physicians to be involved in the priority settingprocess?9 How well do you think the values of VIHA have beenincorporated into priority setting activity? How shouldthe values of VIHA be incorporated into the priority set-ting process?AcknowledgementsFunding for this research project was provided by the Canadian Institutes for Health Research. Francois Dionne is funded by the Western Regional Training Center for Health Services Research and a Canadian Institutes for Health Research Doctoral Research Award. Craig Mitton is funded by the Canada Research Chairs Program and the Michael Smith Foundation for Health Research. Cam Donaldson holds the Health Foundation Chair in Health Economics. The authors are grateful to the reviewers for their help-ful comments.References1. Evans RG: Extravagant Americans, Healthier Canadians: TheBottom Line in North American Health Care.  In Canada andthe United States: Differences that Count 3rd edition. Edited by: ThomasDM. Peterborough, Canada: Broadview Press; 2006. 2. Mitton C, Donaldson C: Priority Setting Toolkit: A guide to the use of eco-nomics in healthcare decision making London: BMJ Publishing Group;2004. 3. Martin DK, Singer PA: A Strategy to Improve Priority Settingin Health Care Institutions.  Health Care Analysis 2003,11(1):59-68.4. Singer PA, Martin DK, Giacomini M, Purdy L: Priority setting fornew technologies in medicine: A Case Study.  BMJ 2000,321(7272):1316-18.5. 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