Priority setting in Ontario`s LHINs
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Transcript Priority setting in Ontario`s LHINs
Priority setting in Ontario's LHINs:
Ethics & economics in action
Jennifer Gibson, PhD
University of Toronto Joint Centre for Bioethics
Craig Mitton, PhD
School of Population & Public Health,
University of British Columbia
On behalf of the LHIN Priority Setting Working
Group
Session Goal & Objectives
Goal: To share experience with developing a
priority setting framework for Ontario’s
Local Health Integration Networks (LHINs)
Objectives:
-
-
To introduce an interdisciplinary priority setting
framework based on ethics and economic
principles
To describe its implementation & evaluation in
Ontario’s LHINs
To identify key lessons learned
Guiding Principles
Economic principles of ‘value for money’
-
What priorities should be set to optimize
health benefits & achieve health system
goals in resource constraints?
Ethical principles of fair process
-
How should these priorities be set to ensure
legitimacy and fairness in the eyes of
affected stakeholders?
Priority Setting Approaches
ECONOMICS
Program budgeting &
marginal analysis
(PBMA)
ETHICS
Accountability for
reasonableness (A4R)
PUBLICITY
1
2
3
4
5
FAIR
PROCESSES
RELEVANCE
1
REVISION
EMPOWERMENT*
5 2
OPTIMAL BENEFITS
*Gibson, Martin & Singer. SSM 2005; 61:
2355–2362.
ENFORCEMENT
Interdisciplinary Approach
PUBLICITY
RELEVANCE
REVISION
1
2
3
4
5
1
EMPOWERMENT
5 2
ENFORCEMENT
Gibson, Mitton, et al., JHSRP 2006;
11(1): 32-37.
LHIN Priority Setting
Project
Background: Ontario’s LHINs
Launched in 2005
No direct service provision - responsible for
planning, coordinating, & funding services
Gradual devolution of accountability from
ministry to LHINs (early 2007)
Project Goal
To develop a priority setting framework that
would help LHINs:
−
Align resources strategically with system
goals and population needs
−
Facilitate constructive stakeholder
engagement
−
Make publicly defensible decisions based on
available evidence and community values
−
Demonstrate public accountability for finite
health resources
Project Overview
PHASE I
PHASE II
PHASE III
PHASE IV
Development
Implementation
• LHIN Pilots (3)
Evaluation
Refinement
Oct ’07…
Feb ’08…
Nov ’08…
Feb-Mar ‘09
Phase I. Development
1a. Criteria: Link decisions explicitly to
local/system strategic plans, population needs,
system values, & performance goals
STRATEGIC FIT
LHIN and MOH strategic plans; Provider system role (mandate & capacity)
POPULATION HEALTH
Health status, prevalence, health promotion/ prevention
SYSTEM VALUES
Client-focus, partnerships, community engagement, innovation, equity, operational
efficiency
SYSTEM PERFORMANCE
Access, quality, sustainability, integration
1b. Criteria-based Decision Tool: Rate/rank
funding options systematically to ensure
consistent rationale across decisions
Step 1. Compliance Screen
Legal/regulatory
Contractual Agreements (e.g., AAs)
1
2
3
4
5
1
2
3
4
5
Step 2. Evaluation (15 criteria)
Step 3. Cost-Benefit Analysis
Step 4. System Readiness Screen
1
1 3
5 2
LHIN capacity
Interdependency
Risk
Health system impact
2. Processes: Establish overall legitimacy and
fairness of decisions, including constructive
stakeholder involvement
4. Develop decision criteria
with stakeholder input.
3. Clarify existing
resource mix.
5. Identify & rank funding
options.
1
2
3
4
5
2. Identify priority setting
committee.
1
1. Determine aim & scope
of decision making.
1 3
6. Communicate decision
& rationale.
1
2
3
4
5
5 2
7. Provide formal decision
review process.
8. Evaluate & improve.
Gibson, et al., Healthcare Quarterly 2005, 8(2);
Mitton & Donaldson, The Priority Setting Toolkit, BMJ Books, 2004.
Phase II. Implementation
Framework piloted in 3 LHINs
Funds available for strategic investment:
$800K - $2M
Success rate: ~10%
Phase III: Evaluation
On-line Survey of health service providers
(n = 110)
Interviews with LHIN Staff (~30) across all
three pilot sites
Analysis:
-
Descriptive analysis - survey data (closed)
Thematic analysis - interviews and survey data
(open-ended)
Evaluation - A4R as a conceptual framework
Key Lessons Learned
Key Findings
Overall, framework perceived to be helpful.
Value of framework
Systematic & disciplined approach
Greater consistency and less subjectivity in DM
Credible basis for explaining decisions
Basis for constructive dialogue about scarcity
internally and externally
Good preparation for ‘high stakes’ re-allocation
(trust-building)
Key Findings
Contextual realities present challenges for
implementation
Challenges
Changing ministry directions
Tight timelines
Inconsistent availability of data
“Promise of benefit” vs. real benefit – need for
performance monitoring
Uneven playing field due to different capacities
of provider organizations (small vs. large)
What counts as fair?
Funding success
Unfunded – somewhat more likely to think
process was not fair (35% vs. 21%)
What counts as fair?
Transparency, transparency, transparency
FAIR
NOT FAIR
LHIN’s goals, criteria, & funding
processes were communicated
clearly.
85%
Agreed
60%
Disagreed
LHIN’s funding rationales were
communicated clearly.
52%
Agreed
89%
Disagreed
Concluding comments
Trust is more not less important during a
time of system transformation and
change.
Incremental implementation and open
evaluation may be key tools to advance
trust within the system.
Interdisciplinary project is unfinished time to engage organizational change
theory.
Priority setting in Ontario's LHINs:
Ethics & economics in action
[email protected]
[email protected]
Questions?
Comments?