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Table 5 Factors influencing the SHARE pilot disinvestment project

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
▪ The project funders had significant impact on the project  - Political support for new technology ▪ The other health services in the consortium also had significant impact  - Collaboration with some of the other health services in writing pathway and documents and developing database and implementation strategies was helpful ▪ Manufacturer’s information was useful ▪ Manufacturer’s technical representative was helpful ▪ The project funders had significant impact on the project  - Monash Health informed that they had to lead a consortium of health services in implementing the new technology, adding complexity to the original application  - Lack of consultation in choice of partner health services  - Requirements for data collection and reporting changed during the project ▪ The other health services in the consortium also had significant impact  - Slow and difficult to coordinate when working with other health services  - Lack of accountability in some of the other health services  - Lack of ‘buy-in’ from other health services through the entire process
Organisational environment (Monash Health)
▪ Monash Health’s reputation as a leader will facilitate new technology support ▪ Monash Health encourages innovation ▪ Support from Centre for Clinical Effectiveness (CCE) ▪ Support from Clinical Program Directors ▪ Support from Finance Department and having someone who can translate the finance jargon ▪ Clinical Resource Nurse monthly meetings ▪ Nursing/Allied Health collaboration ▪ Although staff leave and secondments are difficult there can also be an advantage of working with replacement staff who become familiar with the project ▪ Organisational processes appear to be changing regularly ▪ Lack of clarity around organisational structures and processes eg who to go to for what, when etc. ▪ Lack of communication eg machine delivered to a corridor on a Friday afternoon and left unsecured over the weekend. A component was lost and a new component had to be purchased. ▪ Relevant patient group and clinical expertise in this area located at site A and new machine is at site B. Patients usually scheduled for surgery at A will have to transfer to B. ▪ Sites have different cultures and processes and patients and staff will have to adapt ▪ Impact on other departments eg Sterilisation department has to learn new procedure ▪ Staff secondments and/or leave
Identification process (VPACT application process for introduction of new TCP)
▪ Proposed by potential adopters (nursing/allied health and surgeons) ▪ Support from CCE to provide supporting evidence ▪ Support from Clinical Information Management to provide supporting data ▪ Application form is really long and a lot of work ▪ Lack of awareness of the workload prior to commencing work on application
Prioritisation and decision-making process (SHARE process to determine disinvestment project)
▪ VPACT funding and endorsement ▪ Clinical project team keen to access CCE expertise and support for project delivery  
Rationale and motivation
▪ To reduce harm, improve patient outcomes, improve service efficiency, save money ▪ Emphasis on financial/economic outcomes
Proposal for change
▪ There is good evidence to support the new technology ▪ Data on patient group, burden of disease, impact of new technology provided in detail ▪ New technology does not cause long lasting/irreversible damage ▪ Easy to use ▪ Proposal for change is clear ▪ Relative advantage is clear: improved outcomes for both patients and health service ▪ Endorsed by clinical leaders, good local engagement, clinical champions ▪ Surgeons allowed to keep the theatre time and reduce their own waiting lists (rather than reallocating to other surgical specialties or closing theatres to realise savings) ▪ Longer time to set up than other treatment options ▪ Lots of protective clothing which can be uncomfortable ▪ Mentally and physically tiring ▪ The whole process of change including administration, training, support, etc. is a lot of work
Potential adopters (Nursing and Allied Health staff to undertake new procedure, surgeons to reduce old procedure, junior medical staff to refer patients appropriately
▪ Most surgeons happy to relinquish old procedure to allow them to undertake other procedures ▪ Surgeons involved in VPACT application have become an authority on the new technology ▪ Senior clinical staff read up on new technology as they don’t want to lose face ▪ Registrars (referrers) are supportive of/have an interest in new technologies ▪ General interest among staff ▪ Nursing/Allied Health team look professional, able to build credibility and trust with patients ▪ One group of surgeons less likely to refer patients for new procedure, do not appreciate role of podiatrist in patient care, lack of understanding of treatment options ▪ Some surgeons/medical staff have issues with territorialism and ego
Potential patients
▪ Patients with chronic conditions are more open to trying new treatments ▪ This group of patients are less likely to be comfortable travelling to different hospitals ▪ Lack of English language can be a problem
Implementation plan
▪ Small training workshops with medical teams ▪ Support from CCE ▪ Support from Clinical Program Directors ▪ Maintenance of a booking system ▪ Quarterly meetings with all participating health services ▪ Should have performed barriers and enablers analysis earlier in process ▪ Involvement of other hospitals with staff who are not dedicated/committed (eg disputes among doctors from another site) ▪ Having to repeat training every 3–6 months due to staff rotations ▪ Attrition of podiatrists and Clinical Nurse Consultants as they are often young women who leave or work part-time to have or care for children ▪ Keeping the team motivated is hard ▪ VPACT did not meet costs stipulated in application; fewer machines, limited consumables, etc. ▪ Lack of dedicated treatment room increases time for preparation and cleaning. Clinical time is small in comparison to set up/clean up time. Inadequate ventilation (aerosols are created with treatments)
Evaluation plan
▪ Support from CCE in development of evaluation plan ▪ Having a person in charge of data entry ▪ ‘Shifting the goal posts’ by VPACT regarding data collection and reporting
Implementation and evaluation resources
▪ Other clinical staff voluntarily take up extra workload (both barrier and enabler) ▪ Support from CCE in design of a database, assistance with data entry and reporting ▪ Support from SHARE health economist in development of cost-comparison plan ▪ Monash Health ‘Scope of practice’ processes and documents were helpful ▪ Inadequate funding for clinical staff to implement and evaluate change process ▪ Other clinical staff voluntarily take up extra workload (both barrier and enabler) ▪ Time needed to write up new scope of practice documents