About SHARE
Background
Aims
Research questions
Methods
Case study
Environmental scan
Scanning taxonomy
Scope and sampling
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cover a wide range of decisions including purchase of capital equipment and clinical consumables; introduction of TCPs in diagnostic and treatment settings; development and/or approval of local protocols and guidelines; implementation of services, programs and models of care; and allocation of staff and organisational capacity in clinics, operating rooms and other facilities; and elicit knowledge and previous experience of disinvestment
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include a range of executives, managers, clinicians and consumers
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represent multiple health professional groups, campuses and clinical specialties
Data collection
Interviews
Workshops
Document analysis
Data analysis
Synthesis and interpretation
Development of the new framework
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Familiarisation occurred during organisation of the data.
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Identification of emergent themes was undertaken in preparation of individual reports for each activity which were used for project decision-making and planning.
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Indexing and charting of all responses within the emergent themes was undertaken when combining these reports to address the research questions, confirming the concepts within the new framework.
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Mapping and interpretation identified the relationships between the concepts.
Results
Framework for the process of resource allocation in a local health service
Concepts
Relationships
Building on existing theory
COMPONENTS | STRUCTURE (Who, What) | PRACTICE (How) |
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1. Governance | ▪ Overseers ▪ Policies for decision-making ▪ Transparency and accountability in all structures ▪ Requirements for addressing conflict of interesta
▪ Requirements for monitoring, evaluation and improvement of systems and processes
b
▪ Requirements for reporting
| ▪ Oversight ▪ Procedures, guidelines, protocols for decision-making ▪ Transparency and accountability in all practices ▪ Methods of addressing conflict of interest ▪ Methods of monitoring, evaluation and improvement of systems and processes ▪ Methods of reporting |
2. Administration | ▪ Administrators ▪ Requirements for administration ▪ Relationships and coordination ▪ Communication | ▪ Methods of administration, coordination, communication and collaboration |
3. Stakeholder engagement | ▪ Clinicians, Managers, Consumers, Technical experts, Funders, other relevant parties ▪ Requirements for stakeholder engagement | ▪ Methods of identification, recruitment and engagement |
4. Resources | ▪ Funding sources ▪ Allocation of staff ▪ Access to experts or ways to gain expertise ▪ Information sources ▪ Requirements for resources | ▪ Provision of appropriate and adequate funding, time, skills/training, information ▪ Utilisation of resources |
5. Decision-making | ▪ Decision-makers − Clinicians − Authorised individuals − Authorised groups ▪ Scope of decisions ▪ Type of decisions ▪ Requirements for decision-making | ▪ Methods of decision-making − Identification of need/application − Decision criteria − Ascertainment and use of evidence − Reminders and prompts to consider disinvestment − Deliberative process − Documentation and dissemination |
6. Implementation | ▪ Purchasers ▪ Requirements for purchasing | ▪ Methods of purchasing |
▪ Policy and guidance developers ▪ Requirements for policies and guidance documents
| ▪ Methods of policy and guidance development | |
▪ Implementers ▪ Requirements for implementation
| ▪ Methods of project management ▪ Methods of change management | |
7. Evaluation | ▪ Evaluators ▪ Requirements for evaluation
▪ Type and source of data collected | ▪ Methods of evaluation |
8. (Reinvestment) |
▪ Requirements for reinvestment/reallocation |
▪ Methods of reinvestment/reallocation |
Where, how and by whom are decisions about resource allocation made, implemented and evaluated at Monash Health?
1. Governance
2. Administration
3. Stakeholder engagement
4. Resources
5. Decision-making
DECISION-MAKERS |
Clinicians |
Health practitioners delivering patient care. |
Authorised individuals |
Authorised individuals include Board Members, Executive Directors, Directors and Managers at all levels within the organisation. They are designated by their role in the organisation, for example ‘Director of Pharmacy’, rather than as a named individual ‘John Smith’. |
Authorised groups |
Authorised groups can be classified into those with |
▪ ongoing roles and responsibilities for decisions such as the Board, Executive Management Team, Standing Committees, Approved Purchasing Units and Profession-specific groups such as the Nursing Executive. |
▪ a specific, often time-limited, purpose such as a project Steering Committee, a Procurement Evaluation Committee to purchase a large piece of equipment and special initiatives like the High Cost Drugs Working Party of the Therapeutics Equivalence Program. |
SCOPE OF DECISIONS |
Clinicians make decisions for individual patients within the limits of parameters outlined in their position description, relevant professional standards and any local credentialing requirements. |
Authorised individuals and groups make decisions on behalf of the organisation which impact on all patients, all staff or identified subgroups. |
Individuals are authorised to make decisions on behalf of the organisation within a range of specified parameters outlined in their position description or the Authority Delegation Schedule. |
Committees and other groups are authorised to make decisions on behalf of the organisation as stipulated in their Terms of Reference. |
Examples of the parameters decision-makers are authorised to work within include, but are not limited to, location (eg South East sites), professional group (eg occupational therapists), specialty area (eg stomal therapy), patient group (eg children), nature of purchase or resource use (eg surgical equipment and consumables) and cost limit (eg up to $10,000). |
TYPES OF DECISIONS |
Clinical |
▪ Clinical decisions arise in the encounter between a health practitioner and an individual patient or client. Their purpose is to assess, treat and/or plan ongoing management of a health issue. |
Strategic, operational or professional |
▪ Strategic decisions point the organisation in the direction it wants to go; they are captured in strategic goals and policies which reflect a particular position, priority or plan the organisation wishes to communicate to staff, patients and other stakeholders. Strategic planning is usually undertaken at organisation-level driven by the Board, Executive and Senior Managers but can also be undertaken at any level. |
▪ Operational decisions make the strategic goals happen; they enable day-to-day operations and are undertaken by managers at all levels. |
▪ Professional decisions address standards and methods of practice and are made by senior staff in the discipline to which they are relevant. |
Routine, reactive or proactive |
▪ Routine decisions are made on a regular basis; examples include annual budget setting processes, monthly committee meetings and reviews of guidelines or protocols at specified intervals after their introduction. |
▪ Reactive decisions are made in response to situations as they arise; for example new legislation, product alerts and recalls, critical incidents and applications for new drugs to be included in the formulary. |
▪ Proactive decisions are driven by information that was actively sought for this purpose such as accessing newly published research evidence to compare against current practice or interrogating local data to ascertain practices with high costs or high rates of adverse events. |
Conditional or unconditional |
▪ Conditional decisions specify requirements to be met before or after their implementation; for example availability of funding, clinical indications (eg disease/condition, severity, patient group), authorised practitioners (eg specific training, named individuals), monitoring of outcomes (eg patient outcomes, adverse events, costs), location (eg ICU, Hospital in the Home ), time limitation (eg until 2 year review). |
▪ Unconditional decisions have no requirements. |
Allocating funds or non-monetary resources |
▪ Allocating funds involves spending money or putting it aside to purchase specified items later. |
▪ Allocating non-monetary resources can include rostering staff time; specifying health professional groups; providing clinic or operating room time; and developing protocols that direct use of clinical interventions, equipment, drugs, diagnostic tests and referral mechanisms. |
Whether to buy or what, where and how to buy |
▪ ‘Whether to buy’ is a decision about what is required, for example a new drug to improve patient outcomes, a new scanner to reduce waiting time, consumables for a piece of equipment in current use. These decisions are undertaken by authorised individuals and some of the authorised groups such as Technology/Clinical Practice Committee, Therapeutics Committee, Falls Prevention Committee, etc. |
▪ ‘What, where and how to buy’ is a decision about how the requirement is met and considers product and manufacturer reliability, availability of parts and tools, service and maintenance contracts, IT requirements for hardware and software, price negotiations, etc. These decisions are undertaken by the Approved Purchasing Units and groups established for specific purchases. |
Purchase of budgeted or unbudgeted items |
▪ Decisions to purchase budgeted items are made by the relevant authorised individual, usually the budget holder or their line manager depending on the purchase price and the designated cost limits of their respective approval levels (eg < $10,000, <$50,000). |
▪ Decisions to purchase unbudgeted items can only be approved by specified committees and Executive Directors |
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Government or externally mandated change such as new legislation, regulation or standards; national or state initiatives; and product alerts and recalls.
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Clinician or management initiatives arising from awareness of successful projects elsewhere, conference presentations, journals and other publications, and drug and equipment manufacturer promotions.
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Problem solving driven by critical incidents, staff or consumer feedback, changing population needs, changing demand for services and budget shortfalls.
WHETHER TO BUY | WHAT, WHERE AND HOW TO BUY | |||||
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Organisation-wide Committee | Program Committee | Department | Individual decision-makers | Approved Purchasing Units | Organisation-wide Committee | Department |
Introduction of new health technologies and clinical practices | Purchase of capital equipment | Purchase of capital equipment | Determination of clinical practices and purchase of clinical equipment | General purchasing | Purchase of clinical consumables | Purchase of pharmaceuticals |
Explicit criteria required for decision-making | Criteria ‘usually’ considered A weighted ranking is used for prioritisation | Theoretical ‘ideal’ criteria developed in workshop (different to criteria used in current practice) | Criteria ‘usually’ considered | Criteria ‘usually’ considered | Criteria ‘usually’ considered | Criteria ‘usually’ considered |
▪ Conflict of interest (Applicant and Committee members) ▪ Evidence of safety, effectiveness and cost-effectiveness (quality of evidence, size of effect and applicability addressed) ▪ Cost ▪ Clinical feasibility (resource implications, training, credentialing and competency assurance addressed) ▪ Access and equity ▪ Legal and ethical implications ▪ Suitable patient information brochure | ▪ Equipment serviceability and impact ▪ Clinical risk ▪ Occupational Health and Safety risk ▪ Accreditation and regulatory requirements ▪ Strategic importance to Monash Health ▪ Savings in operational cost and/or ability to generate funds ▪ Improved access | ▪ Workload management ▪ Clinical evidence ▪ Patient benefit ▪ Need ▪ Prioritisation of patient groups ▪ Waiting list ▪ Benchmarking ▪ Replacement for obsolescence ▪ Staff capacity ▪ Allocated budget ▪ Ongoing costs ▪ Funding opportunities ▪ Financial benefit to health service ▪ Multi-use of expensive capital ▪ State-wide planning and coordination ▪ Impact on other areas | ▪ Quality and safety/clinical risk ▪ Reducing complications ▪ Ease of use ▪ Staff capacity ▪ Cost/cost effectiveness ▪ Consumer demand ▪ Delivery time of machines ▪ Brand changes (implications for spare parts, training, etc.) ▪ Training needs of staff and consumers ▪ Quality of care | All APU purchase decisions are made with commercial/financial consideration including ▪ Price ▪ Cost-effectiveness ▪ Improved supply chain efficiencies Other factors considered ▪ Clinical need ▪ Legal issues including Health Purchasing Victoria contract requirements | ▪ Price ▪ Australian standards and regulations for quality and safety ▪ Infection control/ Occupational Health and Safety standards ▪ Serviceability ▪ Business administration such as supply chain and logistics ▪ Meets organisation’s clinical emphasis and infrastructure requirements ▪ Clinical acceptability and effectiveness | ▪ Labelling ▪ Quality ▪ Price ▪Pharmaceutical Benefit Scheme status ▪ Acceptance |
6. Implementation
7. Evaluation
Process (implementation) and Impact (practice change) |
▪ Progress Reports for new TCPs including number of patients treated, number waiting, new referrals (6 monthly) |
▪ Medication safety audits (twice yearly) |
▪ Continual Review Evaluation through Australian Council of Healthcare Standards Guide (dates in Nursing Strategic Plan) |
▪ Established surveillance mechanisms of transfusion practices (ongoing) |
▪ Audits of transfusion practice (random, on behalf of Department of Human Services) |
▪ Incident reports (as they arise, documented in Riskman software) |
Practitioner outcomes |
▪ Survey/interview data including user satisfaction and comments (after project implementation) |
▪ Clinical practice audits (quarterly) |
▪ Incident reports (as they arise, documented in Riskman software) |
Patient outcomes |
▪ Progress Reports for new TCPs including patient outcomes and adverse events (6 monthly) |
▪ Reports of adverse events related to new TCPs (at the time of occurrence) |
▪ Infection Control surveillance mechanisms (ongoing) |
▪ Incident reports (as they arise, documented in Riskman software) |
Economic outcomes |
▪ Clinical Information Management databases of routinely-collected data used to assess |
− Cost of falls and falls-related injuries (as required) |
− Cost of increased length of stay (as required) |
− Costs of products (as required) |
− Costs of procedures (as required) |
System outcomes |
▪ Applications for new TCPs including anticipated implications of new TCP on other areas such as intensive care or pharmacy |
▪ Reports of 2 year review after introduction of new TCP including actual implications of new TCP on other areas |
8. Reinvestment
What factors influence resource allocation processes?
Strengths and weaknesses
Barriers and enablers
Differences between medical and nursing decisions
What knowledge or experience of disinvestment exists within Monash Health?
Discussion
Limitations
Contribution of this study
Systems and processes for resource allocation
Decision-makers
Types of decisions
Criteria for decisions
Implications for policy and practice
Strengths and weaknesses
Opportunities for disinvestment
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decision-making contexts such as meeting agendas, strategic planning, budgeting, explicit decision-making criteria, application forms, development processes for guidelines and protocols, and authorisation processes
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implementation contexts such as purchase orders, guidelines and protocols, clinical paths, checklists, communication strategies and education programs
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evaluation contexts such as development of performance indicators, audits and reviews
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decision-makers could be targeted for training to be aware of disinvestment possibilities or provided with examples of successful disinvestment initiatives
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types of decisions could be explored for disinvestment opportunities
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requirements for consideration of disinvestment could be introduced into documents governing scope of decisions such as position descriptions and committee Terms of Reference.