About SHARE
Background
Aims
Findings of the SHARE Program
Phase One
Specifying the context
Understanding the problem
Defining the components
Phase Two
Aim 1. Systems and processes
Aim 2. Disinvestment projects
Aim 3. Support services
Aim 4. Program evaluation and research
Phase Three
Conceptual review (Paper 9) | Operational review (Paper 10) |
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▪ Terminology and concepts - Health technologies - Disinvestment - Resource allocation - Optimising health care - Reinvestment ▪ Motivation and purpose - Impetus for disinvestment - Rationale for disinvestment ▪ Relationships with other health paradigms - Evidence based health care - Quality improvement - System redesign - Health economic approaches ▪ Challenges ▪ New approach to disinvestment | ▪ Existing theories, frameworks and models ▪ New framework - Audience - Application - Definitions - Concepts - Components ▪ Principles of decision-making ▪ Settings - Decision-making infrastructure - Specific initiatives - Individual decision-makers ▪ Prompts and triggers ▪ Steps in the disinvestment process ▪ Methods and tools ▪ Barriers and enablers |
Terminology and concepts
Motivation and purpose
Relationship with other healthcare improvement paradigms
Challenges
Redefining disinvestment
Theories, frameworks and models
New framework for an organisation-wide approach to disinvestment in the local healthcare setting
Strengths and limitations
Contribution of the SHARE Program
Disinvestment in general – key messages | Sourcea |
▪ Understanding of systems, processes and influencing factors at the local health service level are important for successful disinvestment. | A |
▪ Single definitions for disinvestment and health technologies, are needed with agreement between researchers, policy makers and health service decision-makers [8, 30]. We propose the following definitions. ‑ Disinvestment is removal, reduction or restriction of any aspect of the health system for any reason. Removal indicates complete cessation, reduction is a decrease in current volume or delivery sites, and restriction is narrowing of current indications or eligible populations. This is a broad definition, in essence the conceptual opposite of investment. It is an outcome of, rather than a reason for, a resource allocation decision. It is not burdened with the explanations and caveats of current research definitions. This could apply equally to products, devices and equipment; clinical practices and procedures; health services and programs; information technology and corporate systems. ‑ Health technologies are products, devices and equipment used to deliver health care (eg prostheses, implantable devices, vaccines, pharmaceuticals, surgical instruments, telehealth, interactive IT and diagnostic tools). This is a narrow definition which reflects the common use by decision-makers and consumers in the local health care setting. Clinical practices, support systems, and organisational and managerial systems are not considered to be health technologies in this context. ‑ Health technologies and clinical practices (TCPs) are therapeutic, diagnostic and preventative interventions (eg use of products, devices and equipment PLUS medical, surgical, nursing, allied health and population health activities). This is a pragmatic definition that reflects the scope of most resource allocation decisions related to delivery of health care in the local setting. ‑ Health programs and services are agencies, facilities, institutions and the components within them that deliver acute health care, rehabilitation or population health practices such as health promotion and education. | C |
Disinvestment in general – recommendations | |
A | |
‑ TCPs, services and programs that harm patients, diminish health outcomes, impair health care delivery, increase costs unnecessarily or result in organisational waste should be removed, reduced or restricted to address these adverse outcomes. ‑ If there are opportunities to replace TCPs, services and programs that are safe, effective and cost-effective with others that offer greater advantage no explanation is needed other than the expected benefit. ‑ If budgets are cut or funding is required for high priority activities it is worth remembering that health service staff place a high value on transparency and are disillusioned by attempts to disguise cost reduction methods. | A |
▪ Expand existing healthcare improvement paradigms and research domains (eg EBP, health technology assessment, guideline development, implementation science, knowledge translation, quality improvement, system redesign, health economics, etc) to address the need for theories, frameworks, methods and tools for [8, 23, 24, 26‐30]: ‑ systematic and proactive identification of harmful, ineffective and inefficient TCPs, services and programs ‑ implementation of interventions to remove, reduce or restrict TCPs, services and programs ‑ evaluation of the process, impact and outcomes of these changes ‑ measurement of savings if possible ‑ reallocation of resources if appropriate | A |
▪ The principles for a rigorous, evidence-based approach to decision-making for disinvestment in the context of all resource allocation decisions are incorporated into the Framework for an organisation-wide approach to disinvestment in the local healthcare setting (Figure 5) | A |
Disinvestment in the local health service setting – key messages | |
▪ Decisions to proceed with a project to implement change are often made without consideration of research evidence and local data and are not well-defined in terms of the intervention, practitioner group, patient population, indications, etc. ‑ Clinicians are frequently asked to undertake projects in their area of clinical expertise but they lack knowledge and skills in project management, implementation and evaluation. ‑ Clinicians are usually required to conduct a project in addition to their normal duties but without additional time or resources. ‑ Health service staff are well aware of their limitations and those of their colleagues in undertaking projects and they welcome advice and support. ‑ There are many decision-making settings and processes within health services ‑ There are many components in the research allocation process in addition to decision-making that need to be addressed ‑ There are insufficient resources and skills in decision-making, implementation and evaluation ‑ Staff need support | A |
▪ Decision-making for resource allocation at the local level is not homogenous. Contrary to some assumptions in previous studies, there are multiple layers of decision-making with different actors, criteria, systems and processes. [24] | D |
A | |
Disinvestment in the local health service setting – recommendations | |
▪ Introduce a framework for an organisation-wide approach to disinvestment underpinned by evidence-based principles [30] | A |
▪ Focus on optimising health care and using resource effectively rather than cost-cutting | A |
D | |
▪ Consider settings for decisions about both monetary (eg capital procurement and clinical purchasing) and non-monetary (eg development and authorisation of guidelines and protocols that stipulate use of drugs or equipment, recommend diagnostic tests, specify referral mechanisms etc) resources as opportunities to identify TCPs that should be removed, reduced or restricted. [23, 26, 27, 30] | D |
A | |
▪ Ensure that proposals are fully developed before making decisions to proceed including consideration of research evidence and local data to determine the nature and scope of the problem and the most effective solution; clarification of the intervention and scope of the project in terms of practitioner group, patient population, indications, etc; and assessment of feasibility, risk and cost of implementation and evaluation. [28] | D |
▪ Ensure appropriate knowledge and skills and adequate resources are available for effective project design, management and governance; implementation and evaluation | A |
A | |
A | |
▪ Develop mechanisms to receive and act upon consumer or community-initiated feedback on resource allocation decisions. [25] | D |
New approaches
New knowledge
Organisational decision-making
Consumer participation
Disinvestment process
Addressing and understanding barriers and enablers
New resources
Research questions | Outputs |
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SHARE 2: Identifying opportunities for disinvestment in a local healthcare setting | |
▪ What concepts, definitions and perspectives underpin disinvestment? ▪ 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 local health service network? | ▪ Framework and detailed discussion of potential settings and methods for disinvestment in the local healthcare context ▪ Summary of issues to consider in development of an organisational program for disinvestment ▪ Interview protocol for ascertaining local implications for disinvestment |
SHARE 3: Examining how resource allocation decisions are made, implemented and evaluated in a local healthcare setting | |
▪ Where, how and by whom are decisions about resource allocation made, implemented and evaluated at Monash Health? ▪ What factors influence these processes? ▪ What knowledge or experience of disinvestment exists within Monash Health? | ▪ Framework of eight components in the research allocation process, the elements of structure and practice for each component, and the relationships between them ▪ Classification of decision-makers, decision-making settings, type and scope of decisions, strengths and weaknesses, barriers and enablers ▪ Examples of decision-making criteria and types and sources of evaluation data used ▪ Interview and workshop protocols for ascertaining local decision-making systems and processes |
SHARE 4: Exploring opportunities and methods for consumer engagement in resource allocation in a local healthcare setting | |
▪ How can consumer and community values and preferences be systematically integrated into organisation-wide decision-making for resource allocation? | ▪ Model for integrating consumer values and preferences into decision-making for resource allocation ▪ Definitions for consumer engagement terminology ▪ Examples of sources of consumer information and data ▪ Examples of consumer-related activities generating proactive decisions to drive change |
SHARE 5: Developing a model for evidence-driven resource allocation in a local healthcare setting | |
▪ What are the implications for disinvestment at Monash Health? ▪ What is the most appropriate and effective approach to organisation-wide, systematic, integrated, evidence-driven disinvestment at Monash Health? ▪ Can a model for evidence-driven resource allocation in the local healthcare setting be derived from the Monash Health program to enable replication and testing? | ▪ Model for exploring Sustainability in Health care by Allocating Resources Effectively in the local healthcare setting ▪ Definition of four program components, aims and objectives, relationships between components, principles that underpin the program, implementation and evaluation plans, and preconditions for success and sustainability. ▪ Summary of implications for disinvestment in the local setting and resulting decisions for program development ▪ Summary of factors for program sustainability ▪ Evaluation framework and plan |
SHARE 6: Investigating methods to identify, prioritise, implement and evaluate disinvestment projects in a local healthcare setting | |
▪ What methods are available to identify potential disinvestment opportunities in a local health service? ▪ What methods are available for prioritisation and decision-making to initiate disinvestment projects in a local health service? ▪ What methods are available to develop, implement and evaluate disinvestment projects in a local health service? ▪ What were the processes and outcomes of application of these methods at Monash Health? ▪ What factors influenced the decisions, processes and outcomes? | ▪ Framework for evaluation and explication of a disinvestment project ▪ Examples of criteria for selection of disinvestment projects ▪ Methods for developing an evidence-based catalogue of potential disinvestment opportunities ▪ Algorithm for selecting a disinvestment project from an evidence-based catalogue of potential disinvestment opportunities ▪ Summary of barriers and enablers to implementation and evaluation ▪ Summary of factors related to determinants of effectiveness arising in SHARE process and disinvestment projects |
SHARE 7: Supporting staff in evidence-based decision-making, implementation and evaluation in a local healthcare setting | |
▪ What is current practice in accessing and using evidence for making, implementing and evaluating decisions at Monash Health? ▪ What decisions were made and outcomes achieved in the piloting of support services? ▪ What factors influenced the decisions, processes and outcomes? | ▪ Matrix of barriers, enablers, additional needs and evidence-based interventions mapped to their corresponding components in four support services to enable evidence-based decision-making, implementation and evaluation ▪ Summary of factors influencing decision-making for development of support services ▪ Summary of factors influencing the outcomes of the SHARE support services piloting process ▪ Summaries of current practice, knowledge, skills, confidence and needs in finding, accessing and using evidence for making, implementing and evaluating decisions; and preferred formats for education and training ▪ Summaries of nature, type and availability of local health service data; data sources; uses and expertise available ▪ Evaluation framework and plan |
SHARE 8: Developing, implementing and evaluating an Evidence Dissemination Service in a local healthcare setting | |
▪ What are the potential features of an Evidence Dissemination Service in a local healthcare setting? ▪ How can high quality synthesised evidence be identified, captured, classified, stored, repackaged and disseminated? ▪ How can disseminated evidence be used to enhance current practice and how can use of evidence be reported? ▪ What are the processes and outcomes of disseminating evidence to self-selected and targeted participants in a voluntary framework? ▪ What are the processes and outcomes of disseminating evidence to designated decision-makers in a mandatory governance framework? ▪ What factors influenced the decisions, processes and outcomes? | ▪ Two models for an Evidence Dissemination Service (EDS) in a local healthcare service ▪ Methods for identification, capture, classification, storage, repackaging and dissemination of evidence ▪ Methods to facilitate use of disseminated evidence and reporting of outcomes ▪ Taxonomy for categorising publications ▪ Framework for evaluation and explication of implementation of health information products and services ▪ Summaries of factors influencing decisions, processes and outcomes in development and delivery of the EDS |
SHARE 9: Conceptualising disinvestment in a local healthcare setting | |
▪ Aims: To discuss the current literature on disinvestment from a conceptual perspective, consider the implications for local healthcare settings and propose a new definition and two potential approaches to disinvestment in this context to stimulate further research and discussion. | ▪ Discussion of the disinvestment literature in relation to terminology and concepts, motivation and purpose, relationships with other health improvement paradigms, challenges, and implications for policy, practice and research in local healthcare settings |
SHARE 10: Operationalising disinvestment in a conceptual framework for resource allocation | |
▪ Aims: To discuss the current literature on disinvestment from an operational perspective, combine it with the experiences of the SHARE Program, and propose a framework for disinvestment in the context of resource allocation in the local healthcare setting. | ▪ Discussion of the disinvestment literature from an operational perspective in local healthcare settings ▪ Summary of theories, frameworks and models used in disinvestment-related activities ▪ Framework for evidence-based disinvestment in the context of resource allocation - Standardised definitions and concepts to underpin framework - Principles for resource allocation decision-making - Potential activities and settings for disinvestment - Potential prompts and triggers to initiate disinvestment decisions - Methods and tools for disinvestment - Barriers to disinvestment |
SHARE 11: Reporting outcomes of an evidence-driven approach to disinvestment in a local healthcare setting | |
▪ Aims: To consolidate the findings, discuss the contribution of the SHARE Program to the knowledge and understanding of disinvestment in the local healthcare setting, and consider the implications for policy, practice and research. | ▪ Summary of outcomes of the SHARE Program ▪ Key messages ▪ Implications for research, policy and practice |
SHARE National Workshop | |
▪ Aim: To share knowledge of disinvestment and develop links for future collaborative work opportunities | ▪ Summary of disinvestment activities from health policy, health economics and health service perspectives ▪ Tools for group activities discussing disinvestment concepts and decision-making ▪ Tools for individual activities to capture information about current practice and research in disinvestment ▪ Workshop presentations ▪ Workshop evaluation tool and findings ▪ Summary of key messages |
Implications for policy, practice and research
Recognising the relevance of the local healthcare perspective
Aligning definitions
Enhancing organisational decision-making, implementation and evaluation
Developing proactive processes to initiate evidence-based disinvestment
Adapting, testing and refining SHARE innovations
Conclusion
Acknowledgements
Funding
Availability of data and materials
Authors’ information
Ethics approval and consent to participate
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“The data being collected and analysed is coincidental to standard operating procedures with standard equipment and/or protocols;
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The data is being collected and analysed expressly for the purpose of maintaining standards or identifying areas for improvement in the environment from which the data was obtained;
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The data being collected and analysed is not linked to individuals; and
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None of the triggers for consideration of ethical review are present.” [105]
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Health care providers, managers, consumer representatives, and officers within government health departments will be informed about the project and the processes and invited to participate.
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Participation in interviews, workshops and/or surveys will be considered to be implied consent.