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Table 1 Factors influencing resource allocation at Monash Health

From: Sustainability in Health care by Allocating Resources Effectively (SHARE) 6: investigating methods to identify, prioritise, implement and evaluate disinvestment projects in a local healthcare setting

Positive Negative
External environment
▪ Legislation, regulations, national and international standards, and professional standards must be followed. This provides clarity and certainty for some decisions ▪ International bodies and national agencies of other countries provide evidence-based recommendations for use of health technologies, clinical practices, models of care, etc. Systematic reviews and Health Technology Assessments are also available. ▪ The Australian government provides evidence-based recommendations for use of medical and surgical procedures and drugs ▪ Monitoring, evaluation and reporting of outcomes was required for government funded projects ▪ Department of Treasury is interested in supporting disinvestment initiatives but requires details of savings. If savings or reinvestments can be quantified the department may provide more funding ▪ Some decision-makers are unaware of mandatory requirements ▪ Decision-makers are frequently unaware of evidence-based resources. ▪ Due to lack of time, knowledge and skills decision-makers do not actively seek these resources when making decisions and do not differentiate between high and low quality resources. ▪ Not all medical and surgical procedures and drugs are covered by national policies; nursing and allied health practices, models of care and clinical consumables are not covered ▪ Cost-effectiveness data is often based on modelling which is perceived not to reflect reality ▪ It is hard to measure savings; savings are rarely realised because they are absorbed and used to treat more patients
Organisational environment (Monash Health)
▪ Enthusiastic and dedicated staff; staff commitment to quality improvement ▪ Organisational support from the Executive Management Team (EMT) and Directors of Nursing ▪ The Board, EMT and Senior Managers have expressed ‘patient-centred care’ as a priority. ▪ Involvement of people who are outside of, or uninterested in, the politics of the organisation ▪ Transparency and accountability in decision-making was highly valued and improved transparency and accountability at Monash Health was desired ▪ At site level there is good ‘buy-in’ for change and people are keen to make things work ▪ Organisational culture is difficult to change ▪ Organisational politics gets in the way ▪ Considerable pressures on the health service to reduce costs. ▪ Lack of processes for project development, implementation, responsibility and accountability ▪ Lack of transparency in all aspects ▪ Lack of transparency and accountability in decision-making reduces confidence; inadequate transparency and accountability was one of the strongest messages ▪ No systematic processes to link projects across the organisation
Identification process
▪ Projects were identified reactively based on  - Government or externally mandated change such as new legislation, regulation or standards; national or state initiatives; and product alerts and recalls.  - Clinician or management initiatives arising from awareness of successful projects elsewhere, conference presentations, journals and other publications, and drug and equipment manufacturer promotions.  - Problem solving driven by critical incidents, staff or consumer feedback, changing population needs, changing demand for services and budget shortfalls. ▪ Monash Health had well-documented processes for purchasing and procurement and guideline and protocol development and high level expertise in evidence synthesis and utilisation, data analysis and utilisation, and system redesign ▪ General perceptions that  - financial drivers stronger than clinical drivers, ‘Sound practice is not always affordable practice’  - impetus for change was ad hoc, there was no systematic or proactive approach  - internal bureaucracy and red tape stifled ideas ▪ People by-pass the system and just make changes, usually not deliberate but due to lack of awareness of processes ▪ Some applications for change are driven by pharmaceutical or equipment manufacturers ▪ No examples of using purchasing and procurement, guideline and protocol development, evidence from research or local data, health economic approaches or system redesign to identify potential opportunities for disinvestment were identified
Prioritisation and decision-making process
▪ Using research evidence and local data in decision making was considered to be important. ▪ All respondents reported using research evidence and data in decision-making to some extent. ▪ Many examples of cross-unit/department consultation and collaboration for policy and protocol development and implementation. ▪ Conflict of Interest was required as a standing item on the agendas of relevant committees. Most committees had a process for conflict of interest for committee members, and some of those with an application process had a similar procedure for applicants. ▪ Only one committee and one individual used explicit, documented decision-making criteria ▪ Only one committee required explicit inclusion of research and local data and considered the quality and applicability of this evidence. Only one of the ten projects appraised the evidence used. The other committees had no process to seek evidence from research. When evidence from research and data was used it was not usually appraised for quality or applicability. ▪ Barriers to using research evidence include no uninterrupted blocks of time, slow computers, lack of skills in finding and analysing evidence ▪ Appropriate local data was frequently reported to be lacking, unavailable and ‘manipulated’ ▪ Decision-making ‘in isolation’, ‘fragmentation’ and a ‘silo mentality’ were reported in relation to decisions made without consideration of the areas they would impact upon or consultation with relevant stakeholders.
Rationale and motivation
▪ Reasons for previous ‘disinvestment-type’ projects to remove, restrict or replace current practices include reducing patient harm, reducing medication error, reducing unnecessary tests, improving communication, standardising care, saving money and saving time. Most projects had more than one of these objectives ▪ Perceived distinction between ‘what the hospital is concerned about (finances, organisational capacity and risk management) and what the clinician is concerned about (patients)’.
Proposal for change
▪ When the benefits of the proposed practice change are clear and observable ▪ When there is clarity, relevance, credibility and reliablity of research findings ▪ Availability of quality and timely local data ▪ Sustainability more likely if a range of staff involved, ‘bottom-up’ approaches to change used and monitoring of outcomes undertaken ▪ Lack of baseline data meant that potential adopters were unable to see the benefit or relevance to their situation resulting in less ‘buy in’ and poor uptake.
Potential adopters
▪ Having the appropriate profession engaging others in change process, for example nurses should be implementing projects with nurses, not pharmacists ▪ Flexible and adaptable staff ▪ Resistance to change ▪ Staff cynicism about the importance of changes and relevance to them ▪ Some clinicians insist on autonomy in their areas of expertise
Potential patients
▪ Many respondents supported increased consumer participation and were planning to act upon this ▪ Only one committee included consumer representation in decision-making. ▪ Several respondents thought that consumer representation on their committees would be inappropriate or that consumers had insufficient technical understanding to participate.
Implementation plan
▪ Decisions made at program level that involve multiple wards, departments or sites are usually implemented by multidisciplinary teams ▪ Allowing wards to nominate themselves for participation in projects ▪ ‘Bottom up’ approach to develop individual implementation plan in each ward ▪ Those with project ‘champions’ unanimously considered champions important to the success of the project. ▪ Lots of preparation including training and communication with all stakeholders ▪ ‘Bottom up’ training to gain staff ‘buy in’ combined with ‘top down’ supportive strategy ▪ Training or education included passive methods using posters and memos, interactive learning on new equipment and participatory approaches involving staff in design and implementation. ▪ Things take a long time to implement, to the point that they ‘fall off the agenda’ ▪ Variability in current practice and lack of standardisation increases number of practices to change ▪ Large size, nature and diversity of the organisation increases complexity of implementation across departments with different needsLack of effective implementation pathways ▪ Lack of infrastructure, technical support and resources ▪ High staff turnover in the organisation, particularly agency nurses and junior staff, increases difficulty in communication and implementation ▪ Organisational culture is difficult to change ▪ Organisational politics ▪ High staff turnover in projects diminishes organisational knowledge and expertise and increases training requirements ▪ Competing priorities ▪ Lack of time, undertaking projects while continuing normal clinical duties ▪ One project had no implementation plan ▪ Education and training is not well provided for part-time and night staff
Evaluation plan
▪ Evaluation and monitoring were considered important and had broad support ▪ Routine clinical audits and monitoring of adverse events undertaken for hospital accreditation purposes provided indirect evaluation of decisions in some situations. ▪ No requirements for evaluation of outcomes of decisions or projects. ▪ Most committees had no planned evaluation of outcomes of decisions or implementation projects. ▪ Quality and Risk Managers are not included at the beginning to help with collection of baseline data and evaluation design
Implementation and evaluation resources
▪ Finding others who have done the same work for support, advice and information ▪ Establishing Working Parties and Steering Committees for support, endorsement, troubleshooting ▪ Project leader whose primary role is ‘at the coal face’ ▪ CCE was establishing an in-house Evaluation Service at the time of these interviews ▪ Use of pre-existing, pre-tested tools from other organisations eg audit tools ▪ Provision of extra staff ▪ Availability of extra funds enhanced implementation and evaluation, eg introduction of the National Inpatients Medication Chart had external funding specifically for implementation and evaluation ▪ Some clinical pathways involve no additional costs ▪ Some projects were provided with adequate resources for implementation and evaluation ▪ Some wards had additional staffing for education support and clinical nurse support. These were invaluable resources for practice change, protocol development and implementation. ▪ Some projects had external funding from DHS, universities, etc. for staff or infrastructure costs ▪ CCE ran training programs in finding and using evidence, implementation and evaluation ▪ Six of 10 projects had training for project staff in change management, leadership or IT skills. ▪ Unrealistic project timelines ▪ Lack of knowledge, skills and confidence in project management, change management, evaluation methods and tools, and use of information technology. These barriers were exacerbated when interventions were complex and required high levels of training ▪ Lack of/inadequate project management and communication resulted in multiple people making inconsistent changes ▪ Some project staff felt isolated and would have liked support from others who had done the same or similar work ▪ It was not always clear who was responsible for project management ▪ Staffing issues, including leave, mean that a lot of projects are on hold ▪ High staff turnover in projects diminishes organisational knowledge and expertise and increases training requirements ▪ No specified evaluators with appropriate training or expertise had been utilised by the respondents ▪ A lack of data was seen to contribute to the current state of ‘little or no process of evaluation’. ▪ Lack of/inadequate funding, lack of information about available funding ▪ Funding for new equipment frequently did not include funding for training staff to use it or the consumables required. ▪ Many projects were to be carried out ‘within existing resources’. Respondents noted that they either did unpaid overtime or aspects of the project were not undertaken. ▪ Staff dissatisfaction with the expectation of their superiors that they will do more work within existing resources