Table 4 Factors influencing decisions for program development
Finding | Source | Decision | Program element |
|---|---|---|---|
Potential benefits of disinvestment identified | Literature | Establish a program exploring disinvestment at Monash Health. | SHARE program |
External environment supportive of disinvestment program | Literature & DHS documents | ||
Internal environment supportive of disinvestment program | Monash Health Staff | ||
Capacity for leadership in this area demonstrated | Success of new TCP program | ||
The word ‘disinvestment’ is associated with negative connotations, high risk of engendering suspicion and distrust and getting stakeholders offside. | Literature Monash Health Staff | Proceed carefully, avoid the term ‘disinvestment’ and use positive language. | Principles |
‘Top down’ approach seen as negative. Needs to be balanced with ‘bottom up’ strategies and involvement of stakeholders. | Literature Monash Health Staff | Implement ‘top down’ and ‘bottom up’ strategies, make stakeholder engagement a priority, and integrate methods for staff to drive change into the new systems and processes. | Principles |
Preconditions | |||
A systematic integrated approach would be better than ad hoc decisions, individuals ‘championing’ causes or projects undertaken in isolation. | SHARE leaders International experts | Focus on organisation-wide approach to decision-making that integrates new and current systems and processes. | Principles |
Perceived lack of transparency and accountability and suboptimal use of evidence in current decision-making processes. Power struggles and hidden agendas perceived to influence outcomes. | Monash Health Staff Project team | Ensure the new systems and processes are transparent, accountable and evidence-based. Introduce explicit criteria for disinvestment decisions. | Principles |
Lack of transparency and accountability in reallocation of funding released through disinvestment would be significant barrier to effective program. | |||
Lack of consistent terminology, absence of decision-making criteria and no guidance to inform an organisational approach. | Literature International experts | Develop our own frameworks and methods. | Principles |
Disinvestment should not be considered in isolation but alongside other decisions. Investment and disinvestment decisions are often linked, disinvestment occurs when something new is introduced. | Monash Health Staff SHARE leaders Project team | Do not focus on ‘disinvestment’ or ‘investment’ alone. Consider ‘resource allocation’. Establish processes along decision-making continuum from introduction to removal. | Principles |
Health service staff perceive management priorities to be focused on saving money. The concepts around ‘disinvestment’ accentuate this. | Literature Monash Health Staff | Focus on ‘effective application of health resources’ to facilitate a positive approach. | Principles |
The program needs a strong positive image that reflects the new focus on ‘effective application of health resources’. Being compatible with ‘iCARE’, the familiar acronym for Monash Health values would be beneficial. | Monash Health Staff SHARE leaders Project team | Change the name from ‘Disinvestment Project’ to ‘SHARE’ (Sustainability in Health care by Allocating Resources Effectively) | Name |
Six potential opportunities to integrate disinvestment decisions into organisational infrastructure, systems and processes were identified. | Literature SHARE leaders | Investigate methods to implement disinvestment decisions in the six settings identified. | Systems and Processes |
Undertaking disinvestment projects was a key element of the original proposal. Waiting for investigation of the six settings is too long to delay pilot projects. Some ‘quick wins’ would be valuable. | SHARE leaders Monash Health Staff | Develop methods to identify and prioritise potential target TCPs in parallel with the investigation of the six settings. Undertake pilot projects to disinvest them. | Disinvestment projects |
Current decisions are made ‘routinely’ or ‘reactively’. Introduction of TCPs is based on applications from clinicians or managers and removal of TCPs is based on emerging problems or product alerts and recalls. Research literature and local data could be used ‘proactively’ to drive health service practice. | Monash Health Staff SHARE leaders Project team | Build on current ‘routine/reactive’ processes that are done well. Develop new processes to use evidence ‘proactively’ to drive decisions and/or priority setting. Make these explicit elements of the new program. | Principles |
Using evidence ‘proactively’ requires time and attention from decision-makers. The information provided must be trustworthy, applicable and sufficiently important to warrant adding to their workload. | Monash Health Staff SHARE leaders | Develop methods to identify appropriate high-quality information, process and package it for ease of use and deliver it to the relevant decision-makers. | Systems and Processes |
Decisions for resource allocation are delegated to committees and individuals. There are opportunities for improvement in the governance of these processes and to introduce routine consideration of ‘disinvestment’. | Monash Health Staff SHARE leaders Project team | Review processes and governance of decision-making by committees and the authority delegation schedule | Systems and Processes |
There is no guidance on consumer participation in disinvestment activities. | Literature | Develop methods to capture and utilise consumer perspectives and integrate them into the new program. | Systems and Processes |
With a few exceptions, committees and project teams do not routinely involve consumers in making or implementing decisions and the organisation does not have a framework for engaging consumers. | Monash Health Staff Project team | ||
The systems and processes for evidence-based decision-making cannot be delivered without appropriate and adequate skills and support | Literature Monash Health Staff | Develop support services that enable capacity-building and provide expertise and practical assistance | Support Services |
With a few exceptions, staff do not routinely seek evidence for decisions, are unaware of best practice in implementation and do not evaluate outcomes. | Monash Health Staff Project team | Provide expertise, training and support in accessing and utilising evidence in decisions. Provide expertise, training and support in implementing and evaluating evidence-based change. | Support Services |
The main barriers to use of evidence and effective implementation are lack of time, knowledge, skills and resources. | Literature Monash Health Staff | ||
Health service projects are not usually well supported. It is common for funding to be insufficient, timelines inadequate and staff lacking in knowledge and skills in project management, data collection and analysis. | Monash Health Staff Project team | Influence planning of disinvestment projects to ensure adequate resources and appropriate timelines. Provide expertise, training and support in project methods and administration | Support Services |
Disinvestment projects are generally based on health economic principles | Literature | Utilise in-house expertise and take an ‘evidence-driven’, rather than ‘economics-driven’, approach to investigation of disinvestment in the health service context. | Principles |
Monash Health does not have expertise in health economics and does not intend to fund this in the foreseeable future | Monash Health Leaders | ||
Safety, effectiveness, local health service utilisation and benchmarking parameters are possible alternative considerations for disinvestment. | SHARE leaders Monash Health Staff Project team | ||
Monash Health has high-level expertise in accessing and using research evidence and health service data to inform decisions. | |||
Monash Health does not have the level of expertise in health program evaluation required for SHARE and has no expertise in health economics. | Project team | Engage consultants in health program evaluation and health economics to assist in development and evaluation | Preconditions |
There is no guidance to inform a systematic organisational approach. | Literature | Undertake action research to investigate the process of change in addition to program and economic evaluations. Run a national workshop to learn and share information. Disseminate all findings. | Evaluation and Research |
In addition to detailed program and economic evaluation, understanding what happened in the process of investigation, what worked, what didn’t work and why is required. | SHARE leaders Project team | ||
This large program will need funds. It is consistent with the disinvestment agenda of the Victorian DHS who are sympathetic to a funding application. | DHS documents DHS staff | Seek funding from the state health department. | Preconditions |
To be successful this ambitious proposal will need endorsement, support and strategic direction from the highest level and links to those with power and influence in the organisation. | Literature SHARE leaders Project team | Increase membership of the Steering Committee to reflect those best able to provide the appropriate influence, direction and support. | Preconditions |
All projects should be aligned to the Monash Health Strategic Goals. Program activities will be facilitated if integrated into the organisation Business Plan. | SHARE leaders Project team | Align SHARE with the Monash Health Strategic Goals and include program activities in the annual Business Plans | Principles |