Evidence-based Decision Making to Inform Resource Allocation:

Lessons from Western Canada

Craig Mitton and Howard Waldner

National Healthcare Leadership Conference

Saskatoon, Saskatchewan

June 3, 2008

Contact: craig.mitton@ubc.ca

Background: priority setting

• Health organizations the world over are charged with allocating resources within a limited funding envelope

• Surveys in Canada (and elsewhere) have reported uncertainty amongst decision makers on how best to do this

• What is to be done when there are not enough resources to meet all needs

• What is alternatives exist to historical and/ or political allocation processes?

• How can resources be shifted or re-allocated within existing budgets?

• How can evidence be drawn on to support a priority setting process?

Key questions

Evolution of PBMA

• Economic framework to assist decision makers in making choices around limited resources

• Used in health care since 1970s

– 100+ organizations internationally

– Currently being used in health authorities in Alberta and British Columbia; also piloting in the LHINs

• Can be combined with ethical conditions in its application and is as evidence based as time and data allow for

Practical Steps

• Determine aim and scope of activity

• Identify and map resource use

• Form an advisory panel

• Define and weight decision making criteria

• Identify options for investment and disinvestment

• Evaluate investments and disinvestments

• Validation and recommendations

• Communication, evaluation, revision

Peacock et al. BMJ 2006

Expected Outcomes

• Primary benefit for PBMA

• Achieving real resource shifts that are consistent

with strategic decision-making objectives

• Secondary benefits for PBMA

• Evidence driven decisions

• Ownership of planning process

• Transparent and defensible decision making

• Clinician engagement and partnership

Gibson et al. JHSRP 2006Ruta et al. BMJ 2005

Canadian examples

• Chinook Health Region (Alberta)– Surgery, chronic disease

• Headwaters Health Authority (Alberta)– Surgery, long term care

• Calgary Health Region (Alberta)– Macro, children’s services

• Vancouver Island Health Authority (BC)– Macro, within portfolios

• Interior Health Authority (BC)– Community care services

• Northern Health Authority (BC)– Home and community care

• BC Cancer Agency (BC)– Screening, select drug therapies

• North West, Central West and Champlain LHINs– Urgent priorities, Aging at Home, Alternative levels of care

Vancouver Island Health Authority

• 750,000 population

• 17,000 employees

• All of Vancouver Island

• $1.5 billion operating budget (excluding Phys costs)

• 114 service delivery sites

• Strategic planning, commissioning and provider role

• Entire continuum of care - primary care to tertiary care

PBMA implementation

• For the past two years, VIHA has used PBMA in collaboration with researchers from UBC

• Goals of PBMA in VIHA:

– Engage the organization, including physician leadership

– Transparent and evidence-based process

– Greater understanding of the need to make choices

– Achieve greater support for decisions

VIHA’s 2007/08 Process

• Each portfolio presents their service growth and reduction opportunities using business case template; assessment against criteria

• Proposals scored by peers (senior management team)

• Ranking using formal benefit scoring tool

• Marginal analysis trade-off decisions on relative value of releases vs. investments

• Final list validated by the group

• Recommendations to Executive and/ or Board

Patient/Client Safety Healthy Workplace

Access and FlowClient/Patient Focus

Health and Wellness

Net Revenue/ In-kind ResourcesEfficiency

Differential weighting across the criteria

Evaluation Criteriafor Proposals

Decision-making Inputs

DeterminingOperational Priorities:

Identifying Marginsfor Change

DeterminingOperational Priorities:

Identifying Marginsfor Change

Population Needs

Population Needs

Provincial Requirements

/ Targets

Provincial Provincial Requirements Requirements

/ Targets/ Targets

Rating options against pre-defined criteria

Rating options against pre-defined criteria

Stakeholder InputThe CommunityStaff / Doctors

Board

Stakeholder InputThe CommunityStaff / Doctors

Board

Financial DataFinancial Data

Service UtilizationOutput / Outcomes

Data

Business Plan Priorities

Business Plan Priorities

Practice Guidelines &

Standards

Practice Guidelines &

Standards

VIHA’s 2007/08 Process

• 18 service growth initiatives

• Total value of $72M

• 13 service reduction initiatives

• Total $9M in savings potential for 2007/08

VIHA’s 2007/08 Process – sample

1. Close 30 Residential Care Beds ($1.6M)

2. Home Care Growth $6.0M

3. Acute Care Winter Capacity $3.4M

4. End of Life Plan $3.8M

5. Reduction of OR Slates at X ($1.2M)

6. Eliminate X Community Program ($1.5M)

PBMA – A SHOCK TO THE SYSTEM?

Key lessons

• Importance of strong leadership and Board endorsement

• Process alignment with organizational goals and strategies

• Need ‘data’ but still have to make decisions

• Well defined criteria and formal service proposal scoring tool

• Importance of transparency of process and decisions

• Physician engagement in criteria development and validation

• Credible commitment takes time- organizational trust

• Recognition of political overlay and expectation management

Conclusions

• Health care environment is usually politically charged and always complex

– Need a pragmatic framework that can introduce evidence based decision making

– Leadership, leadership, leadership

• Lessons here likely relevant elsewhere as all health organizations faced with making difficult rationing decisions

Questions/ comments

welcome!