About SHARE
Background
Aims
Research questions
Methods
Design
Model for evidence-based change
Framework for design and evaluation of complex interventions
Data collection methods and sources
Research Question | Method | Source |
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What are the concepts, definitions and perspectives that underpin disinvestment? [33] What models or methods of disinvestment have been implemented in hospitals or health services? Where are the opportunities for systematic decisions about disinvestment in a health service? [9] | Literature review | Health databases, Internet |
Survey of external experts | Researchers and health librarians interested in disinvestment (15 respondents) | |
Semi-structured interviews | Executive of the Technology/Clinical Practice Committee representing Executive Directors, Senior Managers, Clinical Directors (4 members) | |
Structured interviews | Key informants purposefully selected to represent Medicine, Surgery, Nursing, Allied Health, Diagnostic Services, Consumers (6 informants) | |
Structured workshops | SHARE Steering Committee: Executive Directors, Senior Managers, Clinical Program Directors, Consumers (20 members) | |
How are decisions about resource allocation currently made at MH? What factors influence decision-making for resource allocation? [1, 29] What knowledge or experience of disinvestment exists within Monash Health? [29] | Structured interviews | Representatives of committees with mandate to make organisation-wide decisions (13 committees); Managers of Approved Purchasing Units (5 managers); Program Directors, Medical Department Heads, Nurse Unit Managers and a Quality Manager in a clinical program with high use of TCPs (9 managers) |
Structured interviews | Representatives of current or completed projects that involved disinvestment-related activities (10 projects) | |
Structured workshops | SHARE Steering Committee: Executive Directors, Senior Managers, Clinical Program Directors, Consumers (20 members) | |
Structured workshop | Decision-makers from a large multi-campus diagnostic service (18 participants) | |
Document analysis | Victorian Department of Human Services and Monash Health documents | |
How can consumer values and preferences be integrated into organisation-wide decision-making processes? [30] | Literature review | Health databases, Internet |
Semi-structured workshops | Consumer Working Group (3 experienced health service consumer representatives and project team members) | |
Structured interviews | Staff responsible for consumer-related activities (2 managers) | |
Structured interviews | Representatives of committees with mandate to make organisation-wide decisions (13 committees); Managers of Approved Purchasing Units (5 managers); Program Directors, Medical Department Heads, Nurse Unit Managers and a Quality Manager in a clinical program with high use of TCPs (9 managers) | |
What do MH decision-makers need to enable access and utilisation of evidence in decision-making? [31] | Literature review | Health databases, Internet |
Structured interviews | Program Directors, Medical Department Heads, Nurse Unit Managers and a Quality Manager in a clinical program with high use of TCPs (9 managers) | |
Electronic survey | Clinicians and senior managers representing all sites, clinical programs and professional groups (141 respondents, 103 surveys fully completed) |
Development of proposal for change
Project team reflection
Analysis and synthesis
Drafting, review and authorisation of components and activities
Objective | Method | Stakeholders and/or Experts |
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To explore, develop and authorise all program elements, documents and proposals | Structured workshops on specific issues and general discussions at routine meetings | SHARE Steering Committee: Executive Directors, Clinical Program Directors, Senior Managers and Consumers. |
To discuss findings of literature review and Consumer Working Group, refine draft consumer participation framework and identify additional issues | Structured workshop | Monash Health Community Advisory Committee |
To incorporate feedback from Monash Health leaders | Presentations and discussions with individuals and groups | Individuals: All Medical Program Directors and General Manager of Allied Health; Groups: Nursing Executive |
To incorporate feedback from Monash Health staff | Invitation to provide contribution | All staff via the ‘All Staff’ email list; and staff interacting with the project team |
To incorporate high level expertise | Consultation | Health Program Evaluator and Health Economist |
To determine communication issues and requirements | Consultation | Monash Health Public Affairs and Communication Department |
To enhance compatibility and alignment with state health department objectives and funding strategies | Consultation | Victorian Department of Human Services Health Technology Unit |
To seek endorsement and support at the highest levels | Presentations and discussions with groups | Executive Management Team; and Monash Health Board |
Assessment of sustainability
Success: A proposal is more likely to be successfully implemented if it meets the following criteria. ▪ It is based on sound evidence or expert consensus ▪ It is presented by a credible organisation ▪ It can be tested and adapted ▪ The relative advantage is evident ▪ It is of low complexity ▪ It is compatible with the status quo ▪ It has an attractive and accessible format |
Sustainability: A proposal is more likely to be sustainable if it has appropriate and adequate provision in each of the following categories. ▪ Structure ▪ Skills ▪ Resources ▪ Commitment ▪ Leadership |
Development of a model
Results
What are the implications for disinvestment at Monash Health?
Finding | Source | Decision | Program element |
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Potential benefits of disinvestment identified | Literature | Establish a program exploring disinvestment at Monash Health. | SHARE program |
External environment supportive of disinvestment program | Literature & DHS documents | ||
Internal environment supportive of disinvestment program | Monash Health Staff | ||
Capacity for leadership in this area demonstrated | Success of new TCP program | ||
The word ‘disinvestment’ is associated with negative connotations, high risk of engendering suspicion and distrust and getting stakeholders offside. | Literature Monash Health Staff | Proceed carefully, avoid the term ‘disinvestment’ and use positive language. | Principles |
‘Top down’ approach seen as negative. Needs to be balanced with ‘bottom up’ strategies and involvement of stakeholders. | Literature Monash Health Staff | Implement ‘top down’ and ‘bottom up’ strategies, make stakeholder engagement a priority, and integrate methods for staff to drive change into the new systems and processes. | Principles |
Preconditions | |||
A systematic integrated approach would be better than ad hoc decisions, individuals ‘championing’ causes or projects undertaken in isolation. | SHARE leaders International experts | Focus on organisation-wide approach to decision-making that integrates new and current systems and processes. | Principles |
Perceived lack of transparency and accountability and suboptimal use of evidence in current decision-making processes. Power struggles and hidden agendas perceived to influence outcomes. | Monash Health Staff Project team | Ensure the new systems and processes are transparent, accountable and evidence-based. Introduce explicit criteria for disinvestment decisions. | Principles |
Lack of transparency and accountability in reallocation of funding released through disinvestment would be significant barrier to effective program. | |||
Lack of consistent terminology, absence of decision-making criteria and no guidance to inform an organisational approach. | Literature International experts | Develop our own frameworks and methods. | Principles |
Disinvestment should not be considered in isolation but alongside other decisions. Investment and disinvestment decisions are often linked, disinvestment occurs when something new is introduced. | Monash Health Staff SHARE leaders Project team | Do not focus on ‘disinvestment’ or ‘investment’ alone. Consider ‘resource allocation’. Establish processes along decision-making continuum from introduction to removal. | Principles |
Health service staff perceive management priorities to be focused on saving money. The concepts around ‘disinvestment’ accentuate this. | Literature Monash Health Staff | Focus on ‘effective application of health resources’ to facilitate a positive approach. | Principles |
The program needs a strong positive image that reflects the new focus on ‘effective application of health resources’. Being compatible with ‘iCARE’, the familiar acronym for Monash Health values would be beneficial. | Monash Health Staff SHARE leaders Project team | Change the name from ‘Disinvestment Project’ to ‘SHARE’ (Sustainability in Health care by Allocating Resources Effectively) | Name |
Six potential opportunities to integrate disinvestment decisions into organisational infrastructure, systems and processes were identified. | Literature SHARE leaders | Investigate methods to implement disinvestment decisions in the six settings identified. | Systems and Processes |
Undertaking disinvestment projects was a key element of the original proposal. Waiting for investigation of the six settings is too long to delay pilot projects. Some ‘quick wins’ would be valuable. | SHARE leaders Monash Health Staff | Develop methods to identify and prioritise potential target TCPs in parallel with the investigation of the six settings. Undertake pilot projects to disinvest them. | Disinvestment projects |
Current decisions are made ‘routinely’ or ‘reactively’. Introduction of TCPs is based on applications from clinicians or managers and removal of TCPs is based on emerging problems or product alerts and recalls. Research literature and local data could be used ‘proactively’ to drive health service practice. | Monash Health Staff SHARE leaders Project team | Build on current ‘routine/reactive’ processes that are done well. Develop new processes to use evidence ‘proactively’ to drive decisions and/or priority setting. Make these explicit elements of the new program. | Principles |
Using evidence ‘proactively’ requires time and attention from decision-makers. The information provided must be trustworthy, applicable and sufficiently important to warrant adding to their workload. | Monash Health Staff SHARE leaders | Develop methods to identify appropriate high-quality information, process and package it for ease of use and deliver it to the relevant decision-makers. | Systems and Processes |
Decisions for resource allocation are delegated to committees and individuals. There are opportunities for improvement in the governance of these processes and to introduce routine consideration of ‘disinvestment’. | Monash Health Staff SHARE leaders Project team | Review processes and governance of decision-making by committees and the authority delegation schedule | Systems and Processes |
There is no guidance on consumer participation in disinvestment activities. | Literature | Develop methods to capture and utilise consumer perspectives and integrate them into the new program. | Systems and Processes |
With a few exceptions, committees and project teams do not routinely involve consumers in making or implementing decisions and the organisation does not have a framework for engaging consumers. | Monash Health Staff Project team | ||
The systems and processes for evidence-based decision-making cannot be delivered without appropriate and adequate skills and support | Literature Monash Health Staff | Develop support services that enable capacity-building and provide expertise and practical assistance | Support Services |
With a few exceptions, staff do not routinely seek evidence for decisions, are unaware of best practice in implementation and do not evaluate outcomes. | Monash Health Staff Project team | Provide expertise, training and support in accessing and utilising evidence in decisions. Provide expertise, training and support in implementing and evaluating evidence-based change. | Support Services |
The main barriers to use of evidence and effective implementation are lack of time, knowledge, skills and resources. | Literature Monash Health Staff | ||
Health service projects are not usually well supported. It is common for funding to be insufficient, timelines inadequate and staff lacking in knowledge and skills in project management, data collection and analysis. | Monash Health Staff Project team | Influence planning of disinvestment projects to ensure adequate resources and appropriate timelines. Provide expertise, training and support in project methods and administration | Support Services |
Disinvestment projects are generally based on health economic principles | Literature | Utilise in-house expertise and take an ‘evidence-driven’, rather than ‘economics-driven’, approach to investigation of disinvestment in the health service context. | Principles |
Monash Health does not have expertise in health economics and does not intend to fund this in the foreseeable future | Monash Health Leaders | ||
Safety, effectiveness, local health service utilisation and benchmarking parameters are possible alternative considerations for disinvestment. | SHARE leaders Monash Health Staff Project team | ||
Monash Health has high-level expertise in accessing and using research evidence and health service data to inform decisions. | |||
Monash Health does not have the level of expertise in health program evaluation required for SHARE and has no expertise in health economics. | Project team | Engage consultants in health program evaluation and health economics to assist in development and evaluation | Preconditions |
There is no guidance to inform a systematic organisational approach. | Literature | Undertake action research to investigate the process of change in addition to program and economic evaluations. Run a national workshop to learn and share information. Disseminate all findings. | Evaluation and Research |
In addition to detailed program and economic evaluation, understanding what happened in the process of investigation, what worked, what didn’t work and why is required. | SHARE leaders Project team | ||
This large program will need funds. It is consistent with the disinvestment agenda of the Victorian DHS who are sympathetic to a funding application. | DHS documents DHS staff | Seek funding from the state health department. | Preconditions |
To be successful this ambitious proposal will need endorsement, support and strategic direction from the highest level and links to those with power and influence in the organisation. | Literature SHARE leaders Project team | Increase membership of the Steering Committee to reflect those best able to provide the appropriate influence, direction and support. | Preconditions |
All projects should be aligned to the Monash Health Strategic Goals. Program activities will be facilitated if integrated into the organisation Business Plan. | SHARE leaders Project team | Align SHARE with the Monash Health Strategic Goals and include program activities in the annual Business Plans | Principles |
What is the most appropriate and effective approach to organisation-wide, systematic, integrated, evidence-driven disinvestment at Monash Health?
Program components, aims and objectives
Principles
Preconditions
Assessment of sustainability
Structure |
▪ A Steering Committee is in place with appropriate Terms of Reference and members that can deliver the required strategic direction, influence and support ▪ A Project Team is in place with clear timelines and deliverables ▪ Areas of responsibility are defined and lines of reporting and accountability are clear |
Skills |
▪ The Steering Committee has expertise in clinical practice, management, finances, operations, legal, ethics, research, information technology, procurement and biomedical engineering ▪ The Project Team has expertise in evidence based practice, knowledge brokerage, implementation and evaluation of change ▪ Additional expertise is available − Collection and analysis of health service utilisation and cost data (Monash Health Clinical Information Management unit) − Program evaluation and health economics (Consultants) |
Resources |
▪ Appropriate funding has been obtained from Monash Health and Victorian Department of Human Services ▪ Accommodation and infrastructure for project team provided within the Centre for Clinical Effectiveness |
Commitment |
▪ Monash Health has committed significant funding and program activities are included in the Business Plan ▪ The Board and Executive Management Team have endorsed the program ▪ Three Executive Directors are on the Steering Committee ▪ The Centre for Clinical Effectiveness has prioritised development of organisational infrastructure to support evidence-based practice as a key element in its workplan |
Leadership |
▪ The same team that developed the award-winning new technology program are leading the SHARE program ▪ Monash Health has expressed a wish to be leaders in disinvestment ▪ The Victorian Department of Human Services has expressed a wish to be leaders in disinvestment ▪ The Centre for Clinical Effectiveness is a leader in enabling evidence-based decision-making ▪ The Steering Committee carries influence (Executive Directors, Program Directors, Senior Management) |
Implementation
Evaluation
Can a model for evidence-driven resource allocation in the local healthcare setting be derived from the SHARE Program to enable replication and testing?
Framework
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▪ The original plan for a project about ‘disinvestment’ was reframed to a program addressing the spectrum of decisions from investment to disinvestment across the organisation.
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▪ There are existing processes at Monash Health for introduction of new TCPs and removal of TCPs in current use, but these are usually ‘reactive’ decisions made in response to internal applications or external notifications.
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▪ Evidence from published research and local data could be used ‘proactively’ to drive decision-making.Table 6Initial draft of SHARE frameworkIntroduction of safe, effective, cost-effective TCPsRemoval of harmful, ineffective, inefficient TCPsReactive (current)• Application processProactive (potential)• Identification of evidence regarding new TCPs that are safer, more effective or more cost-effectiveReactive (current)• Drug alerts, product withdrawalsProactive (potential)• Identification of evidence regarding TCPs in current practice that are less safe, less effective or less cost-effective
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▪The six settings identified as potential opportunities for decision-making in a systematic, integrated organisation-wide program should be explored across the continuum from investment to disinvestment and should address routine, reactive and proactive decision-making processes.
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▪ A ‘program’ of integrated systems and processes identifying TCPs for introduction, restriction or removal would initiate and direct a series of methodologically rigorous ‘projects’ implementing the desired changes.×
Model
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▪ Systems and processes will be required for systematic, integrated, transparent, accountable, evidence-based decision-making in an organisation-wide approach to identification of potential disinvestment opportunities.
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▪ Projects arising from these decisions will be undertaken to confirm potential benefits, harms and the priorities for disinvestment of identified targets, and implement and evaluate disinvestment where appropriate.
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▪ Support services that provide expertise, training and support to decision-makers and project staff in finding and using evidence from research and local data in decision-making, implementation, evaluation and project management will be required for the systems, processes and projects to be successful.
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▪ Evaluation and research of the systems, processes, projects and support services will inform and enable quality improvement, organisational learning and development, and will add to the body of knowledge on disinvestment.
Domain | SHARE features |
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Purpose ▪ descriptive, explanatory or predictive | The model is primarily descriptive to enable replication and testing in other settings. There are also some explanatory elements addressed in the relationships between components, for example the systems, processes and projects are thought to require input from the four support services to ensure successful implementation |
Development ▪ deductive or inductive ▪ supporting evidence | Methods used in development were both deductive and inductive. Evidence from the research literature and other publications, health service staff, consumers and external experts was used. |
Theoretical underpinning ▪ explicit or implicit | No specific theory was used to underpin the model. A theoretical framework for evaluation of implementation of an evidence-based innovation was used to design questionnaires for data collection to inform program development. |
Conceptual clarity ▪ well-described, coherent language for identification of elements ▪ strengths and weaknesses of theories ▪ potential to stimulate new theoretical developments | Four components are outlined in the model. The relationships between them are delineated in a simple diagram. The details of each component, the aims and objectives, are provided in the surrounding boxes. The principles that underpin the program and the preconditions for success and sustainability are also detailed in surrounding boxes. No specific theories were used so no comparisons are made. There is potential for new theoretical developments if: ▪ specific theories are tested in development and implementation of the components ▪ components are removed or the relationships changed ▪ principles or preconditions are varied ▪ the model is applied in contexts other than resource allocation for technologies and clinical practices ▪ the model is applied in settings other than local health service networks |
Level ▪ individual, team, unit, organisation, policy | The program was developed for organisation-wide implementation in a local health service. This approach could also be used at a higher (regional, state/provincial, national) or lower (single facility, department or unit) level, however is unlikely to be applicable to individual decision-makers. |
Situation ▪ hypothetical, real | The model represents actual settings and contexts in health service decision-making and implementation of change. However it could also be used for teaching or capacity building through hypothetical classroom discussions or simulation exercises. |
Users ▪ nursing, medical, allied health, policy makers, multidisciplinary | SHARE focuses on decision-makers at the organisation-wide level in a local health service. This includes senior clinicians, managers and policy makers across all professional disciplines, all clinical settings and some areas of corporate practice (eg finance, procurement, legal, ethics, IT, biomedical engineering); and health service consumers. |
Function ▪ barrier analysis ▪ intervention development ▪ selection of outcome measures ▪ process evaluation | The main function is to enable replication and testing of the SHARE program by capturing the components and their relationships, principles and preconditions. The principle of an evidence-based approach to change requires assessment of barriers and enablers but the model itself does not specifically facilitate this process. The model would assist in development of an intervention for systematic evidence-based decision-making and implementation of change. Evaluation of process and outcomes is a key element, however selection of variables and outcome measures is not facilitated by the model per se, but an evaluation framework and plan has been developed [38]. |
Testable ▪ hypothesis generation ▪ supported by empirical data ▪ suitable for different methodologies | The model describes settings and opportunities, systems and processes, and structures to support decision-making, implementation of change and evaluation of process and outcomes. A range of hypotheses could be developed for each of these elements and the relationships between them which could be tested in a number of ways using various methodologies. |
Discussion
Strengths
Limitations
Implications for policy and practice
Implications for research
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▪ specific theories are tested in development and implementation of the components
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▪ components are removed or the relationships changed
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▪ principles or preconditions are varied
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▪ the model is applied in contexts other than resource allocation for TCPs
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▪ the model is applied in settings other than local health service networks